Provider Demographics
NPI:1417036054
Name:BASSEL ALTANTAWI MD PC
Entity Type:Organization
Organization Name:BASSEL ALTANTAWI MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BASSEL
Authorized Official - Middle Name:
Authorized Official - Last Name:ALTANTAWI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-635-7574
Mailing Address - Street 1:610 PHEASENT WOODS DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188
Mailing Address - Country:US
Mailing Address - Phone:248-635-7574
Mailing Address - Fax:
Practice Address - Street 1:9150 ALLEN ROAD
Practice Address - Street 2:
Practice Address - City:ALLEN PARK
Practice Address - State:MI
Practice Address - Zip Code:48101
Practice Address - Country:US
Practice Address - Phone:248-635-7574
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIBA074111207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1104225970OtherBCBS
MI1104225970OtherBCBS