Provider Demographics
NPI:1013433416
Name:FANOUS, IBRAHIM SAMEH IBRAHIM (MD)
Entity type:Individual
Prefix:
First Name:IBRAHIM
Middle Name:SAMEH IBRAHIM
Last Name:FANOUS
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 1:1500 FIFTH AVE FL 1
Mailing Address - Street 2:
Mailing Address - City:MCKEESPORT
Mailing Address - State:PA
Mailing Address - Zip Code:15132-2422
Mailing Address - Country:US
Mailing Address - Phone:412-664-2782
Mailing Address - Fax:412-664-2784
Practice Address - Street 1:1500 FIFTH AVE FL 1
Practice Address - Street 2:
Practice Address - City:MCKEESPORT
Practice Address - State:PA
Practice Address - Zip Code:15132-2422
Practice Address - Country:US
Practice Address - Phone:412-664-2782
Practice Address - Fax:412-664-2784
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-17
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD471035207R00000X
PAMT212607390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty