1669468336 NPI number — DR. IMAD TAHBOUB MD

Table of content: DR. IMAD TAHBOUB MD (NPI 1669468336)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669468336 NPI number — DR. IMAD TAHBOUB MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TAHBOUB
Provider First Name:
IMAD
Provider Middle Name:
Provider Name Prefix Text:
DR.
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:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1669468336
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/29/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 490
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MCCOMB
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39649-0490
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-250-4366
Provider Business Mailing Address Fax Number:
601-250-4367

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
215 MARION AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MCCOMB
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39648-2705
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-249-5500
Provider Business Practice Location Address Fax Number:
601-249-1173
Provider Enumeration Date:
09/27/2005

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: 207R00000X , with the licence number:  IT053374 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 31196 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 23349 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 03404537 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 131779 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 114594000 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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