Provider Demographics
NPI:1437585106
Name:ELIAS H KASSAB MD PLLC
Entity Type:Organization
Organization Name:ELIAS H KASSAB MD PLLC
Other - Org Name:DEARBORN CARDIOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ELIAS
Authorized Official - Middle Name:H
Authorized Official - Last Name:KASSAB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-724-9000
Mailing Address - Street 1:1360 PORTER ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2823
Mailing Address - Country:US
Mailing Address - Phone:313-724-9000
Mailing Address - Fax:313-562-9300
Practice Address - Street 1:5250 AUTO CLUB DR STE 300
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-2619
Practice Address - Country:US
Practice Address - Phone:313-724-9000
Practice Address - Fax:313-562-9300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-25
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301047006207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1437585106Medicaid