Provider Demographics
NPI:1669468336
Name:TAHBOUB, IMAD (MD)
Entity Type:Individual
Prefix:DR
First Name:IMAD
Middle Name:
Last Name:TAHBOUB
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:PO BOX 490
Mailing Address - Street 2:
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39649-0490
Mailing Address - Country:US
Mailing Address - Phone:601-250-4366
Mailing Address - Fax:601-250-4367
Practice Address - Street 1:215 MARION AVE
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-2705
Practice Address - Country:US
Practice Address - Phone:601-249-5500
Practice Address - Fax:601-249-1173
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIIT053374207R00000X
AL31196207R00000X
MS23349207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03404537Medicaid
AL131779Medicaid
AL131779Medicaid
MION85110Medicare PIN
MS364527YQH8Medicare PIN