Basic Information
| Provider Information | |||||||||
| NPI: | 1336673219 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALRAYES | ||||||||
| FirstName: | TABATHA | ||||||||
| MiddleName: | |||||||||
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| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | WYDRYCK | ||||||||
| OtherFirstName: | TABATHA | ||||||||
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| OtherCredential: | DO | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3031 W GRAND BLVD | ||||||||
| Address2: | SUITE 450 | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482023046 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | CHILDREN'S HOSPITAL OF MI | ||||||||
| Address2: | 3901 BEAUBIEN | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482012119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3137455260 | ||||||||
| FaxNumber: | 3139937166 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2017 | ||||||||
| LastUpdateDate: | 06/03/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 5101025608 | MI | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.