Healthcare Provider Details

I. General information

NPI: 1093715690
Provider Name (Legal Business Name): ESSAM Y. TELLAWI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: SAM Y TELLAWI

II. Dates (important events)

Enumeration Date: 07/26/2005
Last Update Date: 10/15/2025
Certification Date: 10/15/2025
Deactivation Date: 03/21/2006
Reactivation Date: 04/03/2006

III. Provider practice location address

205 N EAST AVE
JACKSON MI
49201-1753
US

IV. Provider business mailing address

1 FORD PL STE 3A
DETROIT MI
48202-3450
US

V. Phone/Fax

Practice location:
  • Phone: 517-205-4800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number4301055821
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number0101040870
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301055821
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberMD-45632
License Number StateIA
# 5
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberD34274
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: