Provider Demographics
NPI:1578505889
Name:ELGABALAWI, FAYEZ (MD)
Entity Type:Individual
Prefix:
First Name:FAYEZ
Middle Name:
Last Name:ELGABALAWI
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 1:4200 MONUMENT RD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19131-1625
Mailing Address - Country:US
Mailing Address - Phone:215-581-3736
Mailing Address - Fax:215-254-2599
Practice Address - Street 1:101 E OLNEY AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19120-2421
Practice Address - Country:US
Practice Address - Phone:215-581-3736
Practice Address - Fax:215-254-2599
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2010-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD035002E2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA610387Medicare ID - Type Unspecified
PAE51523Medicare UPIN