Provider Demographics
NPI:1619915527
Name:FALLOUH, MOHANAD M (MD)
Entity Type:Individual
Prefix:
First Name:MOHANAD
Middle Name:M
Last Name:FALLOUH
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 1:6950 GERMANTOWN AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19119-2114
Mailing Address - Country:US
Mailing Address - Phone:484-443-4406
Mailing Address - Fax:484-448-2203
Practice Address - Street 1:6950 GERMANTOWN AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19119-2120
Practice Address - Country:US
Practice Address - Phone:484-443-4406
Practice Address - Fax:484-448-2203
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301083048207R00000X
PAMD443377207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1103710361OtherBCBSM
MI4847475-10Medicaid
MI1018503OtherMCLAREN HEALTH PLAN
PA440771OtherMLHC MEDICARE AA #
MI4732682-10Medicaid
MI01005838OtherHEALTHPLUS COMMERCIAL
MI4885019-10Medicaid
MI1020183OtherMCLAREN HEALTH PLAN
MI200000005731OtherPHP COMMERCIAL
PA440771OtherMLHC BCBS AA #
MI1016406OtherMCLAREN HEALTH PLAN
MI4847475-10Medicaid
PA440771OtherMLHC BCBS AA #
MIM17400029Medicare PIN
MI1018503OtherMCLAREN HEALTH PLAN
MI1016406OtherMCLAREN HEALTH PLAN
PA23-2359401OtherMLHC TIN
MI4885019-10Medicaid