MEDICARE: EBRAM M FANOUS PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	5501011728	MI

General Provider Information

NPI Number	:	1053502468
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EBRAM M FANOUS PT

Provider Business Mailing Address
First Line	:	3381 HIDDEN OAKS LN
Second Line	:
City	:	WEST BLOOMFIELD
State	:	MI
Zip	:	48324-3256
Country	:	US
Telephone Number	:	586-335-8182
Fax Number	:	248-757-2330

Provider Business Practice Location Address
First Line	:	36430 VAN DYKE AVE
Second Line	:
City	:	STERLING HEIGHTS
State	:	MI
Zip	:	48312-2746
Country	:	US
Telephone Number	:	586-335-8182
Fax Number	:	248-757-2330

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/09/2007
Last Update Date	:	11/05/2024

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