Provider Demographics
NPI:1144209883
Name:FAHS, SHADI M (DO)
Entity Type:Individual
Prefix:DR
First Name:SHADI
Middle Name:M
Last Name:FAHS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:23855 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-1805
Mailing Address - Country:US
Mailing Address - Phone:313-769-5656
Mailing Address - Fax:313-769-5658
Practice Address - Street 1:23855 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-1805
Practice Address - Country:US
Practice Address - Phone:313-769-5656
Practice Address - Fax:313-769-5658
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-11
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101014583208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI238601OtherMEDICARE RURAL HEALTH CLINIC NUMBER
MI4938598Medicaid
MICA1068OtherRAILROAD MEDICAER
MIM20520051Medicare PIN
MICA1068OtherRAILROAD MEDICAER