Ebtisam Faddoul, PA-C

Primary specialty

Physician AssistantTaxonomy code 363A00000X

License

015255-1 Issued in NY

Practice address

29 Hospital PLZ Ste 501
Stamford, CT 06902-3602

Phone

(203) 276-4400

Fax

(203) 276-4401

NPI assigned

Nov 21, 2011

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in CT, NY2 enrollments

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 2

Specialty

Physician Assistant

Education

Mercy College, 2011

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Stamford Health Medical Group IncGroup PAC ID 6901099746, 442 clinicians

Practice addresses (Care Compare)

Merit-based Incentive Payment System (MIPS)

Final score

100 of 100Reported as group

Promoting interoperability

100

Improvement activities

40

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

State licenses

Practice roles

Locations

Networks

• Healthfirst Medicare Network H9678
• Healthfirst Medicare Network H3359
• Healthfirst Medicare Network H5989
• Healthfirst Medicare Network H1722

Interoperability endpoints

• Direct secure messaging: efaddoul24498@stamfordhealth.direct-ci.com

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Stamford Health Medical Group Inc

  • General Practice Physician
  • Stamford, CT
  • NPI 1154633980
  Medicare reassignment Care Compare group
• Montefiore Medical Center

  • Anesthesiology Physician
  • Bronx, NY
  • NPI 1063525152
  Medicare reassignment NPD
• East Post Road Medical Services PC

  • Emergency Medicine Physician
  • White Plains, NY
  • NPI 1841767274
  Medicare reassignment
• Montefiore Medical Center

  • Community/Retail Pharmacy
  • Bronx, NY
  • NPI 1194183715
  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1321833600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1658188800000",
    "number": "1114294055",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "29 HOSPITAL PLZ STE 501",
            "city": "STAMFORD",
            "state": "CT",
            "postal_code": "069023602",
            "telephone_number": "203-276-4400",
            "fax_number": "203-276-4401"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "29 HOSPITAL PLZ STE 501",
            "city": "STAMFORD",
            "state": "CT",
            "postal_code": "069023602",
            "telephone_number": "203-276-4400",
            "fax_number": "203-276-4401"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "111 E 210th St",
            "address_purpose": "LOCATION",
            "city": "Bronx",
            "state": "NY",
            "postal_code": "104672401",
            "country_code": "US",
            "telephone_number": "718-920-2985",
            "fax_number": "718-920-2058",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "FADDOUL",
        "first_name": "EBTISAM",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2011-11-21",
        "last_updated": "2022-07-19",
        "certification_date": "2022-07-19",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "NY",
            "license": "015255-1",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Physician Assistant in Stamford, CT
• Providers in Stamford, CT by specialty
• Physician Assistant in Connecticut

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 19, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.