Healthcare Provider Details

I. General information

NPI: 1346681707
Provider Name (Legal Business Name): SEYED H FAKHRAEE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2013
Last Update Date: 07/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ALI SHARIATI AVE MOFID CHILDREN'S HOSPITAL
TEHRAN TEHRAN
15468
IR

IV. Provider business mailing address

1690 BRIAR RIDGE DR
ANN ARBOR MI
48108-9400
US

V. Phone/Fax

Practice location:
  • Phone: 011982122251736
  • Fax: 011982122251736
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301050957
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: