Provider Demographics
NPI:1003291279
Name:BOFARRAG, FADEL AHMED (MD, MPH)
Entity type:Individual
Prefix:
First Name:FADEL
Middle Name:AHMED
Last Name:BOFARRAG
Suffix:
Gender:M
Credentials:MD, MPH
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 19636
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9636
Mailing Address - Country:US
Mailing Address - Phone:217-545-8000
Mailing Address - Fax:217-545-7063
Practice Address - Street 1:701 N 1ST ST STE D434
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-3757
Practice Address - Country:US
Practice Address - Phone:217-545-8000
Practice Address - Fax:217-545-7063
Is Sole Proprietor?:No
Enumeration Date:2015-07-29
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015014044207R00000X
MA276951207R00000X, 208M00000X
IL036.170263207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist