Healthcare Provider Details

I. General information

NPI: 1215973565
Provider Name (Legal Business Name): MICHAEL S FAKHRAEE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 02/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7500 CENTRAL AVE SUITE 101
PHILADELPHIA PA
19111-2431
US

IV. Provider business mailing address

7500 CENTRAL AVE SUITE 101
PHILADELPHIA PA
19111-2431
US

V. Phone/Fax

Practice location:
  • Phone: 215-728-8200
  • Fax: 215-725-3209
Mailing address:
  • Phone: 215-728-8200
  • Fax: 215-725-3209

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2082S0105X
TaxonomySurgery of the Hand (Plastic Surgery) Physician
License NumberMD018776E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: