Healthcare Provider Details

I. General information

NPI: 1417150681
Provider Name (Legal Business Name): KAMAL FAHIM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2007
Last Update Date: 10/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4717 ST. ANTOINE KRESGE EYE INSTITUTE
DETROIT MI
48201-1423
US

IV. Provider business mailing address

1560 E MAPLE RD SUITE 400 - CREDENTIALING
TROY MI
48083-1138
US

V. Phone/Fax

Practice location:
  • Phone: 313-577-8900
  • Fax: 313-577-0700
Mailing address:
  • Phone: 313-577-8900
  • Fax: 313-577-0700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number4301090236
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number4301090236
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: