1093715690 NPI number — ESSAM Y. TELLAWI M.D.

Table of content: TREANA REDD (NPI 1497361091)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093715690 NPI number — ESSAM Y. TELLAWI M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TELLAWI
Provider First Name:
ESSAM
Provider Middle Name:
Y.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TELLAWI
Provider Other First Name:
SAM
Provider Other Middle Name:
Y
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1093715690
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/15/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/21/2006
NPI Reactivation Date:
04/03/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 FORD PL STE 3A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DETROIT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48202-3450
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
205 N EAST AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49201-1753
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-205-4800
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/26/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  4301055821 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RG0100X , with the licence number: 0101040870 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 4301055821 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0100X , with the licence number: MD-45632 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0100X , with the licence number: D34274 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 04834 . This is a "AMERIGROUP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 54284801 . This is a "CAREFIRST" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 110032815 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 318537 . This is a "ALLIANCE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2980177 . This is a "EVERCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: A618 0001 . This is a "CAREFIRST" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
  • Identifier: 1093715690 . This is a "MEDICAID" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 218537 . This is a "M.D. IPA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4115912 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 026092800 . This is a "MEDICAL ASSISTANCE" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
  • Identifier: 219846 . This is a "BLUESHEILD" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 107596 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 248N273G . This is a "MEDICARE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: G02093S01 . This is a "MEDICARE" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
  • Identifier: 477271700 . This is a "MEDICAL ASSISTANCE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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