Provider Demographics
NPI:1629305057
Name:ABDUL TABBAA MD PC
Entity Type:Organization
Organization Name:ABDUL TABBAA MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ABDUL
Authorized Official - Middle Name:H
Authorized Official - Last Name:TABBAA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:810-742-3400
Mailing Address - Street 1:1501 S CENTER RD
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48509-1731
Mailing Address - Country:US
Mailing Address - Phone:810-742-3400
Mailing Address - Fax:810-742-2534
Practice Address - Street 1:1501 S CENTER RD
Practice Address - Street 2:
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48509-1731
Practice Address - Country:US
Practice Address - Phone:810-742-3400
Practice Address - Fax:810-742-2534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-05
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAT039215208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2110440Medicaid
MI0829827Medicare PIN
MI2110440Medicaid