Basic Information
| Provider Information | |||||||||
| NPI: | 1669468336 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TAHBOUB | ||||||||
| FirstName: | IMAD | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 490 | ||||||||
| Address2: | |||||||||
| City: | MCCOMB | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396490490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012504366 | ||||||||
| FaxNumber: | 6012504367 | ||||||||
| Practice Location | |||||||||
| Address1: | 215 MARION AVE | ||||||||
| Address2: | |||||||||
| City: | MCCOMB | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396482705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012495500 | ||||||||
| FaxNumber: | 6012491173 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2005 | ||||||||
| LastUpdateDate: | 04/29/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | IT053374 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 31196 | AL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 23349 | MS | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 03404537 | 05 | MS | MEDICAID | 131779 | 05 | AL | MEDICAID |