Healthcare Provider Details

I. General information

NPI: 1770826430
Provider Name (Legal Business Name): TARREK HEGAB M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2013
Last Update Date: 09/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 JACKSON ST
SAINT PAUL MN
55101-2502
US

IV. Provider business mailing address

8170 33RD AVE MS: 21110Q
BLOOMINGTON MN
55425-4516
US

V. Phone/Fax

Practice location:
  • Phone: 651-254-3456
  • Fax: 651-254-9673
Mailing address:
  • Phone: 651-254-3456
  • Fax: 651-254-9673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number60455
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: