Provider Demographics
NPI:1467672485
Name:ALHATEM, FADI (MD)
Entity Type:Individual
Prefix:
First Name:FADI
Middle Name:
Last Name:ALHATEM
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:PO BOX 54679
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90054-0679
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:250 N ROBERTSON BLVD STE 505
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211
Practice Address - Country:US
Practice Address - Phone:310-385-3530
Practice Address - Fax:310-385-3322
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2018-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD77403208VP0000X, 208VP0014X
CAC1594082084P2900X
WI55631-20208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Yes2084P2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1467672485Medicaid
WI1467672485OtherANTHEM
MI0210089OtherBCBS
MI1467672485Medicaid
WI1467672485Medicaid