=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053486985
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BASHAR FAHOUM MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/24/2006
-----------------------------------------------------
Last Update Date | 09/20/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 506 6TH ST DEPT OF SURGERY
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11215-3609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-780-3288
-----------------------------------------------------
Fax | 718-780-3154
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 270 FLAGG PL
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10304-1134
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-780-3290
-----------------------------------------------------
Fax | 718-780-3154
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 192383
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2086S0102X
-----------------------------------------------------
Taxonomy Name | Surgical Critical Care Physician
-----------------------------------------------------
License Number | 192383
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------