Provider Demographics
NPI:1801138896
Name:FADEMOS FAMILY PRACTICE
Entity type:Organization
Organization Name:FADEMOS FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/CLINICAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:SALAHOU
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:215-613-5069
Mailing Address - Street 1:16 OLD ASHTON RD STE 1
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19152-1661
Mailing Address - Country:US
Mailing Address - Phone:215-613-5069
Mailing Address - Fax:215-613-6809
Practice Address - Street 1:16 OLD ASHTON RD STE 1
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19152-1661
Practice Address - Country:US
Practice Address - Phone:215-613-5069
Practice Address - Fax:215-613-6809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-18
Last Update Date:2013-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP008704261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care