Provider Demographics
NPI:1508870379
Name:POURTABIB, MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:POURTABIB
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 1:1035 SNOWDON CT
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60540-8251
Mailing Address - Country:US
Mailing Address - Phone:630-420-1820
Mailing Address - Fax:
Practice Address - Street 1:100 SPALDING DR
Practice Address - Street 2:SUITE 102
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-6550
Practice Address - Country:US
Practice Address - Phone:630-355-5860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2215455OtherBLUE CROSS
IL314240Medicare ID - Type UnspecifiedPROVIDER NUMBER
ILC39549Medicare UPIN