Provider Demographics
NPI:1093715690
Name:TELLAWI, ESSAM Y (MD)
Entity Type:Individual
Prefix:
First Name:ESSAM
Middle Name:Y
Last Name:TELLAWI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:SAM
Other - Middle Name:Y
Other - Last Name:TELLAWI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1 FORD PL STE 3A
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-3450
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:205 N EAST AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1753
Practice Address - Country:US
Practice Address - Phone:517-205-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2023-04-24
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-04-03
Provider Licenses
StateLicense IDTaxonomies
MI4301055821207R00000X, 207RG0100X
IAMD-45632207RG0100X
MDD34274207RG0100X
VA0101040870207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
107596OtherCIGNA
GA110032815OtherRAILROAD MEDICARE
VA219846OtherBLUESHEILD
MD477271700OtherMEDICAL ASSISTANCE
218537OtherM.D. IPA
MD54284801OtherCAREFIRST
DCA618 0001OtherCAREFIRST
DC026092800OtherMEDICAL ASSISTANCE
VA1093715690OtherMEDICAID
2980177OtherEVERCARE
04834OtherAMERIGROUP
4115912OtherAETNA
318537OtherALLIANCE
DCG02093S01OtherMEDICARE
MD248N273GOtherMEDICARE
4115912OtherAETNA