Healthcare Provider Details

I. General information

NPI: 1285813329
Provider Name (Legal Business Name): FADI BASSAM YAHYA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2007
Last Update Date: 09/29/2020
Certification Date: 09/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 W FOUNTAIN ST
ALBERT LEA MN
56007-2437
US

IV. Provider business mailing address

404 W FOUNTAIN ST
ALBERT LEA MN
56007-2437
US

V. Phone/Fax

Practice location:
  • Phone: 507-373-2384
  • Fax:
Mailing address:
  • Phone: 507-373-2384
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number0116019718
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number54322
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: