Healthcare Provider Details

I. General information

NPI: 1689225443
Provider Name (Legal Business Name): ALAA EDDIN TAHBOUB PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2019
Last Update Date: 12/13/2024
Certification Date: 12/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4771 MICHIGAN AVE
DETROIT MI
48210-9718
US

IV. Provider business mailing address

17827 MAISONS DR
CLINTON TWP MI
48038-3805
US

V. Phone/Fax

Practice location:
  • Phone: 313-897-2600
  • Fax: 313-897-2424
Mailing address:
  • Phone: 810-845-6450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5601009631
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085007807
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: