Healthcare Provider Details

I. General information

NPI: 1457855777
Provider Name (Legal Business Name): JORDAN TABBAKH MD, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2018
Last Update Date: 09/13/2026
Certification Date: 09/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2450 RIVERSIDE AVE
MINNEAPOLIS MN
55454-1450
US

IV. Provider business mailing address

2450 RIVERSIDE AVE
MINNEAPOLIS MN
55454-1450
US

V. Phone/Fax

Practice location:
  • Phone: 612-273-3000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number82518
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: