1750376877 NPI number — M BASSEM HOSEIN DEKELBAB MD

Table of content: M BASSEM HOSEIN DEKELBAB MD (NPI 1750376877)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750376877 NPI number — M BASSEM HOSEIN DEKELBAB MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEKELBAB
Provider First Name:
M BASSEM
Provider Middle Name:
HOSEIN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DEKELBAB
Provider Other First Name:
M. BASSEM
Provider Other Middle Name:
HOSEIN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1750376877
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/30/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
26901 BEAUMONT BLVD STE 3D
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHFIELD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48033-3849
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
947-522-1867
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3535 W 13 MILE RD
Provider Second Line Business Practice Location Address:
707
Provider Business Practice Location Address City Name:
ROYAL OAK
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48073-6770
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-551-0487
Provider Business Practice Location Address Fax Number:
248-551-3696
Provider Enumeration Date:
09/14/2005

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: 208000000X , with the licence number:  4301059462 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4749714 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".