Provider Demographics
NPI:1568451391
Name:MOHAMMAD B TABAIE, MD PC
Entity Type:Organization
Organization Name:MOHAMMAD B TABAIE, MD PC
Other - Org Name:COSMETIC PLASTIC RECONSTRUCTIVE SURGERY
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMMAD
Authorized Official - Middle Name:B
Authorized Official - Last Name:TABAIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-492-5815
Mailing Address - Street 1:PO BOX 2003
Mailing Address - Street 2:
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-4503
Mailing Address - Country:US
Mailing Address - Phone:315-446-3904
Mailing Address - Fax:315-445-2936
Practice Address - Street 1:4850 BROAD RD
Practice Address - Street 2:SUITE 2G
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13215-5100
Practice Address - Country:US
Practice Address - Phone:315-492-5815
Practice Address - Fax:315-492-5831
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
55806AMedicare ID - Type Unspecified