Provider Demographics
NPI:1568636629
Name:HADLA, TAREK SALIM (MD)
Entity Type:Individual
Prefix:DR
First Name:TAREK
Middle Name:SALIM
Last Name:HADLA
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 1:23902 FORD RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48127-3246
Mailing Address - Country:US
Mailing Address - Phone:313-562-4700
Mailing Address - Fax:
Practice Address - Street 1:23902 FORD RD
Practice Address - Street 2:SUITE A
Practice Address - City:DEARBORN HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48127-3246
Practice Address - Country:US
Practice Address - Phone:313-562-4700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-18
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125052101207Q00000X
MI4301095806207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2509511472OtherBCBS IND
DP595OtherRR MEDICARE GROUP #
P00820812OtherRR MEDICARE INDIVIDUAL #
MI1568636629OtherCOMMERICIAL
ILIL2613OtherMEDICARE GROUP NUMBER
MIP00950697OtherRAILROAD MEDICARE IND PIN
MI15686363329Medicaid
MI2509511472OtherBCN IND
MIP00950697OtherRAILROAD MEDICARE IND PIN
MI2509511472OtherBCN IND