Healthcare Provider Details

I. General information

NPI: 1063826188
Provider Name (Legal Business Name): JALEH FALLAH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2014
Last Update Date: 07/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 BREWSTER ST
PAWTUCKET RI
02860-4474
US

IV. Provider business mailing address

9500 EUCLID AVE
CLEVELAND OH
44195-0001
US

V. Phone/Fax

Practice location:
  • Phone: 401-729-2258
  • Fax: 401-729-3343
Mailing address:
  • Phone: 401-729-2258
  • Fax: 401-729-3343

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberLP03090
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number130636
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: