Provider Demographics
NPI:1205986247
Name:FALLEN TIMBERS INTERNAL MEDICINE, LLC
Entity type:Organization
Organization Name:FALLEN TIMBERS INTERNAL MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NIZAR
Authorized Official - Middle Name:Y
Authorized Official - Last Name:DABOUL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:419-866-6200
Mailing Address - Street 1:6450 WHEATSTONE CT
Mailing Address - Street 2:
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-9402
Mailing Address - Country:US
Mailing Address - Phone:419-866-6200
Mailing Address - Fax:419-866-7170
Practice Address - Street 1:6450 WHEATSTONE CT
Practice Address - Street 2:
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-9402
Practice Address - Country:US
Practice Address - Phone:419-866-6200
Practice Address - Fax:419-866-7170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35072198207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2008562Medicaid
OH2633396Medicaid
OHI49972Medicare UPIN
OH2008562Medicaid
OHG44901Medicare UPIN
OH9325321Medicare ID - Type Unspecified