Provider Demographics
NPI:1558353193
Name:FADEL, HOSSAM ELDIN (MD)
Entity Type:Individual
Prefix:DR
First Name:HOSSAM
Middle Name:ELDIN
Last Name:FADEL
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 1:1348 WALTON WAY
Mailing Address - Street 2:SUITE 5500
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30901-5104
Mailing Address - Country:US
Mailing Address - Phone:706-724-2148
Mailing Address - Fax:706-724-1908
Practice Address - Street 1:1348 WALTON WAY
Practice Address - Street 2:SUITE 5500
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-5104
Practice Address - Country:US
Practice Address - Phone:706-724-2148
Practice Address - Fax:706-724-1908
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA017172207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00014011BMedicaid
GA16BDBCMMedicare ID - Type Unspecified
GAC39574Medicare UPIN