Healthcare Provider Details

I. General information

NPI: 1932194511
Provider Name (Legal Business Name): FADI HADDAD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2005
Last Update Date: 04/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

822 W 1ST ST SUITE 8
BLOOMINGTON IN
47403-2384
US

IV. Provider business mailing address

822 W 1ST ST SUITE 8
BLOOMINGTON IN
47403-2384
US

V. Phone/Fax

Practice location:
  • Phone: 812-331-8168
  • Fax: 812-331-1096
Mailing address:
  • Phone: 812-331-8168
  • Fax: 812-331-1096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number01051484A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: