Provider Demographics
NPI:1326007865
Name:FANOUS-PAUL, AMIRA BOULOS (MD)
Entity Type:Individual
Prefix:
First Name:AMIRA
Middle Name:BOULOS
Last Name:FANOUS-PAUL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 HOSPITAL BLVD
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-4915
Mailing Address - Country:US
Mailing Address - Phone:770-751-2500
Mailing Address - Fax:
Practice Address - Street 1:3000 HOSPITAL BLVD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076
Practice Address - Country:US
Practice Address - Phone:770-751-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY38616207ZP0105X
GA77475207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX177879701Medicaid
8G1810Medicare ID - Type Unspecified
TX177879701Medicaid