Provider Demographics
NPI:1730992009
Name:BASEM FANOUS, M.D. A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:BASEM FANOUS, M.D. A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:BASEM
Authorized Official - Middle Name:
Authorized Official - Last Name:FANOUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-486-8138
Mailing Address - Street 1:20312 HOWARD CT
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91364-5668
Mailing Address - Country:US
Mailing Address - Phone:818-486-8138
Mailing Address - Fax:
Practice Address - Street 1:14124 FOOTHILL BLVD STE 100
Practice Address - Street 2:
Practice Address - City:SYLMAR
Practice Address - State:CA
Practice Address - Zip Code:91342-8051
Practice Address - Country:US
Practice Address - Phone:818-486-8138
Practice Address - Fax:818-486-8138
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-29
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty