=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801053996
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMIR-KIANOOSH M FALLAHI MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2008
-----------------------------------------------------
Last Update Date | 06/27/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14555 LEVAN RD SUITE 116
-----------------------------------------------------
City | LIVONIA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48154-5083
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-464-0400
-----------------------------------------------------
Fax | 734-464-0404
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14555 LEVAN RD SUITE 116
-----------------------------------------------------
City | LIVONIA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48154-5083
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-464-0400
-----------------------------------------------------
Fax | 734-464-0404
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | 125051909
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------