Healthcare Provider Details

I. General information

NPI: 1336448901
Provider Name (Legal Business Name): FADEL BALAWI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2011
Last Update Date: 10/18/2021
Certification Date: 10/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 WOODLAND ST SAINT FRANCIS MEDICAL CENTER, DEPARTMENT OF PEDIATRICS
HARTFORD CT
06105-1208
US

IV. Provider business mailing address

1000 ASYLUM AVE SUITE 2109A
HARTFORD CT
06105-1770
US

V. Phone/Fax

Practice location:
  • Phone: 860-714-5407
  • Fax: 860-714-8218
Mailing address:
  • Phone: 860-714-5058
  • Fax: 860-714-8311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number049844
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number049844
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number249940-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: