Provider Demographics
NPI:1629542832
Name:INTERNAL MEDICINE PRIMARY CARE PA
Entity Type:Organization
Organization Name:INTERNAL MEDICINE PRIMARY CARE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:IMAD
Authorized Official - Middle Name:
Authorized Official - Last Name:TAHBOUB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-519-0509
Mailing Address - Street 1:140 DAUGHDRILL STA
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-8406
Mailing Address - Country:US
Mailing Address - Phone:601-519-0509
Mailing Address - Fax:
Practice Address - Street 1:140 DAUGHDRILL STA
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-8406
Practice Address - Country:US
Practice Address - Phone:601-519-0509
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-22
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty