Provider Demographics
NPI:1851759922
Name:MASSARWEH, FAYSAL
Entity Type:Individual
Prefix:
First Name:FAYSAL
Middle Name:
Last Name:MASSARWEH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6435 W JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-6203
Mailing Address - Country:US
Mailing Address - Phone:260-344-4035
Mailing Address - Fax:260-969-9272
Practice Address - Street 1:1 KISH HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-9602
Practice Address - Country:US
Practice Address - Phone:815-756-1521
Practice Address - Fax:815-748-5789
Is Sole Proprietor?:No
Enumeration Date:2016-02-04
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01076145A207R00000X
IL036165259208M00000X
OH35.131179207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0179577Medicaid
IN201355800Medicaid
IN201355800Medicaid
INP01694726Medicare PIN