Provider Demographics
NPI:1255376638
Name:SHAHRAM TABIB MD A MEDICAL CORPORATION
Entity type:Organization
Organization Name:SHAHRAM TABIB MD A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAHRAM
Authorized Official - Middle Name:
Authorized Official - Last Name:TABIB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-597-9786
Mailing Address - Street 1:8581 SANTA MONICA BLVD
Mailing Address - Street 2:#421
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90069
Mailing Address - Country:US
Mailing Address - Phone:310-597-9786
Mailing Address - Fax:
Practice Address - Street 1:1300 NORTH VERMONT AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027
Practice Address - Country:US
Practice Address - Phone:323-913-4892
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2009-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW18262AMedicare PIN
CAW18261Medicare ID - Type UnspecifiedGRP #