Provider Demographics
NPI:1336173871
Name:FANOUS, BASEM (DPM)
Entity Type:Individual
Prefix:
First Name:BASEM
Middle Name:
Last Name:FANOUS
Suffix:
Gender:M
Credentials:DPM
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 688
Mailing Address - Street 2:
Mailing Address - City:CANDO
Mailing Address - State:ND
Mailing Address - Zip Code:58324-0688
Mailing Address - Country:US
Mailing Address - Phone:701-968-2541
Mailing Address - Fax:701-968-2574
Practice Address - Street 1:HWY 281N
Practice Address - Street 2:
Practice Address - City:CANDO
Practice Address - State:ND
Practice Address - Zip Code:58324-0688
Practice Address - Country:US
Practice Address - Phone:701-968-2541
Practice Address - Fax:701-968-2574
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND32213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND25667OtherBCBS PROVIDER #
ND25923OtherBCBS PROVIDER #
ND17592Medicaid
ND25667OtherBCBS PROVIDER #
U41207Medicare UPIN
ND25923OtherBCBS PROVIDER #