Provider Demographics
NPI:1497797526
Name:ALTANTAWI, BASSEL (MD)
Entity Type:Individual
Prefix:
First Name:BASSEL
Middle Name:
Last Name:ALTANTAWI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 PHEASANT WOODS DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188-3165
Mailing Address - Country:US
Mailing Address - Phone:248-635-7574
Mailing Address - Fax:734-844-3950
Practice Address - Street 1:610 PHEASANT WOODS DR
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48188-3165
Practice Address - Country:US
Practice Address - Phone:248-635-7574
Practice Address - Fax:734-844-3950
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301074111207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP00254230OtherRR MEDICARE
MI104749090Medicaid
MIM88560035Medicare ID - Type UnspecifiedWA FOOTE MEMORIAL
MI104749090Medicaid