Basic Information
Provider Information | |||||||||
NPI: | 1750376877 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DEKELBAB | ||||||||
FirstName: | M BASSEM | ||||||||
MiddleName: | HOSEIN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DEKELBAB | ||||||||
OtherFirstName: | M. BASSEM | ||||||||
OtherMiddleName: | HOSEIN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 26901 BEAUMONT BLVD STE 3D | ||||||||
Address2: |   | ||||||||
City: | SOUTHFIELD | ||||||||
State: | MI | ||||||||
PostalCode: | 480333849 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9475221867 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3535 W 13 MILE RD STE 707 | ||||||||
Address2: |   | ||||||||
City: | ROYAL OAK | ||||||||
State: | MI | ||||||||
PostalCode: | 480736770 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2485510487 | ||||||||
FaxNumber: | 2485513696 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/14/2005 | ||||||||
LastUpdateDate: | 07/15/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/15/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 4301059462 | MI | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 4749714 | 05 | MI |   | MEDICAID |