Healthcare Provider Details

I. General information

NPI: 1891778759
Provider Name (Legal Business Name): FADI T MAALOUF M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/23/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT ST YAW 6A
BOSTON MA
02114-2621
US

IV. Provider business mailing address

297 CHESTNUT W #27 J
RANDOLPH MA
02368-2372
US

V. Phone/Fax

Practice location:
  • Phone: 617-724-6300
  • Fax:
Mailing address:
  • Phone: 617-306-8580
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number222618
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: