Provider Demographics
NPI:1689225443
Name:TAHBOUB, ALAA EDDIN (PA-C)
Entity Type:Individual
Prefix:
First Name:ALAA EDDIN
Middle Name:
Last Name:TAHBOUB
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17827 MAISONS DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-3805
Mailing Address - Country:US
Mailing Address - Phone:810-845-6450
Mailing Address - Fax:
Practice Address - Street 1:4771 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48210-9718
Practice Address - Country:US
Practice Address - Phone:313-897-2600
Practice Address - Fax:313-897-2424
Is Sole Proprietor?:No
Enumeration Date:2019-09-24
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601009631363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical