Provider Demographics
NPI:1558598292
Name:FANOUS, MICHELLE (DO)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:
Last Name:FANOUS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:SHAROBEEM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:RED LION & KNIGHTS ROADS
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19114
Mailing Address - Country:US
Mailing Address - Phone:215-612-4000
Mailing Address - Fax:215-949-7806
Practice Address - Street 1:RED LION & KNIGHTS ROADS
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19114
Practice Address - Country:US
Practice Address - Phone:215-612-4000
Practice Address - Fax:215-949-7806
Is Sole Proprietor?:No
Enumeration Date:2009-06-21
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT012883207P00000X, 207Q00000X
PAOT012883&OS015355207P00000X
PAOS015355&OT012883207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine