Provider Demographics
NPI:1457867988
Name:ELBGAL, IMAD NASSER
Entity Type:Individual
Prefix:
First Name:IMAD
Middle Name:NASSER
Last Name:ELBGAL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6450 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-2259
Mailing Address - Country:US
Mailing Address - Phone:313-216-2200
Mailing Address - Fax:313-584-3622
Practice Address - Street 1:6450 MAPLE ST
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-2259
Practice Address - Country:US
Practice Address - Phone:313-216-2200
Practice Address - Fax:313-584-3622
Is Sole Proprietor?:No
Enumeration Date:2017-12-20
Last Update Date:2017-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist