Provider Demographics
NPI:1205879954
Name:FATHALLA, BASIL M (MD)
Entity type:Individual
Prefix:
First Name:BASIL
Middle Name:M
Last Name:FATHALLA
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 1:4201 ST. ANTOINE
Mailing Address - Street 2:UNIVERSITY PEDIATRICIANS UHC 6F MAILBOX# 226
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-4139
Mailing Address - Country:US
Mailing Address - Phone:313-966-5051
Mailing Address - Fax:
Practice Address - Street 1:3901 BEAUBIEN ST
Practice Address - Street 2:CHILDREN'S HOSPITAL OF MI
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2119
Practice Address - Country:US
Practice Address - Phone:215-427-5094
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2009-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4277872080P0216X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0216XAllopathic & Osteopathic PhysiciansPediatricsPediatric Rheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1014672880001Medicaid
PA1014672880001Medicaid
097803Medicare ID - Type Unspecified