MEDICARE: MICHAEL M. FANOUS, D.P.M., INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213ES0103X	Foot & Ankle Surgery Podiatrist	E3544	CA

General Provider Information

NPI Number	:	1083796726
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MICHAEL M. FANOUS, D.P.M., INC.

Provider Business Mailing Address
First Line	:	2834 HAMNER AVE
Second Line	:	# 113
City	:	NORCO
State	:	CA
Zip	:	92860-1929
Country	:	US
Telephone Number	:	760-951-1238
Fax Number	:

Provider Business Practice Location Address
First Line	:	15366 11TH ST
Second Line	:	SUITE D
City	:	VICTORVILLE
State	:	CA
Zip	:	92395-3726
Country	:	US
Telephone Number	:	760-951-1238
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MICHAEL M. FANOUS
Credential	:	D.P.M.
Telephone Number	:	760-951-1238

Provider Enumeration Date	:	10/20/2006
Last Update Date	:	07/31/2008

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