Provider Demographics
NPI:1922076835
Name:KASSAB, ELIAS HABIB (MD)
Entity Type:Individual
Prefix:
First Name:ELIAS
Middle Name:HABIB
Last Name:KASSAB
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 1:5250 AUTO CLUB DR STE 300
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-2619
Mailing Address - Country:US
Mailing Address - Phone:313-724-9000
Mailing Address - Fax:313-562-9300
Practice Address - Street 1:5250 AUTO CLUB DR STE 300
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-2619
Practice Address - Country:US
Practice Address - Phone:313-724-9000
Practice Address - Fax:313-562-9300
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301047006207RI0011X, 207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI060007968OtherMEDICARE RR
MIP51229OtherBLUECARE NETWORK
MI0Q26305002OtherBLUECROSSBLUESHIELD OF MI
MI1910717Medicaid
A75148Medicare UPIN
MI1910717Medicaid