Provider Demographics
NPI:1124008529
Name:GHANEM, FIRAS (MD)
Entity Type:Individual
Prefix:
First Name:FIRAS
Middle Name:
Last Name:GHANEM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 N. MAYFAIR RD. 2ND FLOOR
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226
Mailing Address - Country:US
Mailing Address - Phone:414-259-7505
Mailing Address - Fax:414-259-7583
Practice Address - Street 1:1185 CORPORATE CENTER DR
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-4887
Practice Address - Country:US
Practice Address - Phone:262-928-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01072445A207R00000X, 207RC0000X, 207RI0011X
WI64436207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCH41135Medicare UPIN