Healthcare Provider Details

I. General information

NPI: 1114231313
Provider Name (Legal Business Name): FARAH TABASSUM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2010
Last Update Date: 07/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 SAINT ANTOINE ST 9C UHC
DETROIT MI
48201-2153
US

IV. Provider business mailing address

4201 SAINT ANTOINE ST 9C UHC
DETROIT MI
48201-2153
US

V. Phone/Fax

Practice location:
  • Phone: 313-745-5147
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0213X
TaxonomyPediatric Pathology Physician
License Number4301089593
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: