Healthcare Provider Details

I. General information

NPI: 1285648329
Provider Name (Legal Business Name): SAMIR F FARAG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3774 RIDGE PIKE SUITE 101
COLLEGEVILLE PA
19426-3169
US

IV. Provider business mailing address

PO BOX 432
GWYNEDD VALLEY PA
19437-0432
US

V. Phone/Fax

Practice location:
  • Phone: 610-489-3333
  • Fax: 610-489-9390
Mailing address:
  • Phone: 610-489-3333
  • Fax: 610-489-9390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD039341L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: