Healthcare Provider Details

I. General information

NPI: 1174903397
Provider Name (Legal Business Name): HUSSAM TALLAB M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2015
Last Update Date: 06/03/2025
Certification Date: 06/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7620 SOUTHERN BLVD STE 1
YOUNGSTOWN OH
44512-5667
US

IV. Provider business mailing address

100 DEBARTOLO PL STE 200
YOUNGSTOWN OH
44512-6095
US

V. Phone/Fax

Practice location:
  • Phone: 330-629-2144
  • Fax: 330-629-2140
Mailing address:
  • Phone: 330-729-8146
  • Fax: 330-965-5229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number263399
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number263399
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number80.000072
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: