=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801115993
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RAOUF TADROS D.O.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/28/2010
-----------------------------------------------------
Last Update Date | 05/15/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 43475 DALCOMA DR STE 100
-----------------------------------------------------
City | CLINTON TWP
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48038-3593
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-263-5043
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4402 WILLOW CREEK DR
-----------------------------------------------------
City | TROY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48085-5726
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-835-4730
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | 5101018079
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------