Provider Demographics
NPI:1356492482
Name:FAHED, ELIE (MD)
Entity Type:Individual
Prefix:DR
First Name:ELIE
Middle Name:
Last Name:FAHED
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 1:6501 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82609-4293
Mailing Address - Country:US
Mailing Address - Phone:307-235-5433
Mailing Address - Fax:307-233-4700
Practice Address - Street 1:6501 E 2ND ST
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82609-4293
Practice Address - Country:US
Practice Address - Phone:307-235-5433
Practice Address - Fax:307-233-4700
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA229811207R00000X
WY8989A207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1356492482Medicaid
WYW25055Medicare PIN