Healthcare Provider Details

I. General information

NPI: 1053502468
Provider Name (Legal Business Name): EBRAM M FANOUS PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2007
Last Update Date: 11/05/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36430 VAN DYKE AVE
STERLING HEIGHTS MI
48312-2746
US

IV. Provider business mailing address

3381 HIDDEN OAKS LN
WEST BLOOMFIELD MI
48324-3256
US

V. Phone/Fax

Practice location:
  • Phone: 586-335-8182
  • Fax: 248-757-2330
Mailing address:
  • Phone: 586-335-8182
  • Fax: 248-757-2330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501011728
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: