Provider Demographics
NPI:1578501748
Name:TAHA, WAEL (MD)
Entity Type:Individual
Prefix:
First Name:WAEL
Middle Name:
Last Name:TAHA
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 1:1560 E MAPLE RD
Mailing Address - Street 2:SUITE 400-CREDENTIALING
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1138
Mailing Address - Country:US
Mailing Address - Phone:313-745-4525
Mailing Address - Fax:313-993-0085
Practice Address - Street 1:4201 ST ANTOINE
Practice Address - Street 2:SUITE 5A
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2153
Practice Address - Country:US
Practice Address - Phone:313-745-4525
Practice Address - Fax:313-993-0085
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301091739207R00000X, 207RE0101X, 207RE0101X
KY13696208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY39094OtherMEDICAL LICENSE
KY64090418Medicaid
000000354853OtherBCBS PROVIDER NUMBER
0935311Medicare PIN
0601436Medicare PIN
0903666Medicare PIN
000000354853OtherBCBS PROVIDER NUMBER
KY64090418Medicaid
I20968Medicare UPIN
KYP00156579Medicare PIN