Provider Demographics
NPI:1609495498
Name:GHOULEH, TAHA SAMIR
Entity Type:Individual
Prefix:
First Name:TAHA
Middle Name:SAMIR
Last Name:GHOULEH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6415 W 84TH ST
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:IL
Mailing Address - Zip Code:60459-2412
Mailing Address - Country:US
Mailing Address - Phone:708-692-8242
Mailing Address - Fax:
Practice Address - Street 1:3400 CIVIC CENTER BLVD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-5127
Practice Address - Country:US
Practice Address - Phone:708-692-8242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-11
Last Update Date:2020-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program