Provider Demographics
NPI:1932561982
Name:GEORGIE, FAWAZ JAN SYRIL (MD)
Entity Type:Individual
Prefix:
First Name:FAWAZ
Middle Name:JAN SYRIL
Last Name:GEORGIE
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 1:30055 NORTHWESTERN HWY STE 220
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-3275
Mailing Address - Country:US
Mailing Address - Phone:248-865-9898
Mailing Address - Fax:248-865-9423
Practice Address - Street 1:30055 NORTHWESTERN HWY STE 220
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-3275
Practice Address - Country:US
Practice Address - Phone:248-865-9898
Practice Address - Fax:248-865-9423
Is Sole Proprietor?:No
Enumeration Date:2016-03-28
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI4301501126207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program