Provider Demographics
NPI:1578890778
Name:SHABAN, HESHAM (MD)
Entity Type:Individual
Prefix:
First Name:HESHAM
Middle Name:
Last Name:SHABAN
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 1:2799 W GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2799 W GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2608
Practice Address - Country:US
Practice Address - Phone:313-916-2600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-09
Last Update Date:2017-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301111998207RH0002X, 207RN0300X
390200000X
PAMT196159390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty