Provider Demographics
NPI:1982633178
Name:FANI SROUR, JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:FANI SROUR
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-887-4530
Mailing Address - Fax:704-887-4531
Practice Address - Street 1:10030 GILEAD RD STE 201
Practice Address - Street 2:
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078
Practice Address - Country:US
Practice Address - Phone:704-887-4530
Practice Address - Fax:704-887-4531
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2019-01351207RC0000X, 207RI0011X
NH13064207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH1170828OtherCIGNA
NH396965OtherMVP
ME432327299Medicaid
NH7984888OtherAETNA
NHAA73407OtherHARVARD PILGRIM
NJ01Y010853NH02OtherBCBS
NH30206253Medicaid
NH5761654OtherFIRST HEALTH
NH5761654OtherFIRST HEALTH
ME432327299Medicaid
NH30206253Medicaid