Provider Demographics
NPI:1275249898
Name:FANOUS CLINIC MEDICAL GROUP PC
Entity Type:Organization
Organization Name:FANOUS CLINIC MEDICAL GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HANY
Authorized Official - Middle Name:
Authorized Official - Last Name:FARAG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-659-5992
Mailing Address - Street 1:9200 WOODHALL LAKE DR
Mailing Address - Street 2:
Mailing Address - City:WAXHAW
Mailing Address - State:NC
Mailing Address - Zip Code:28173-6998
Mailing Address - Country:US
Mailing Address - Phone:216-659-5992
Mailing Address - Fax:
Practice Address - Street 1:9200 WOODHALL LAKE DR
Practice Address - Street 2:
Practice Address - City:WAXHAW
Practice Address - State:NC
Practice Address - Zip Code:28173-6998
Practice Address - Country:US
Practice Address - Phone:216-659-5992
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-26
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty