Healthcare Provider Details

I. General information

NPI: 1184642050
Provider Name (Legal Business Name): MOUSAB I TABBAA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 01/19/2024
Certification Date: 01/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 COLUMBIA RD STE 200
WESTLAKE OH
44145-7215
US

IV. Provider business mailing address

850 COLUMBIA RD STE 200
WESTLAKE OH
44145-7215
US

V. Phone/Fax

Practice location:
  • Phone: 440-808-1212
  • Fax: 440-808-2060
Mailing address:
  • Phone: 440-808-1212
  • Fax: 440-808-0321

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number35053272
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: