Basic Information
| Provider Information | |||||||||
| NPI: | 1952336455 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAHBY | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | F | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 955 S BAILEY AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH HAVEN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490909701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2696375271 | ||||||||
| FaxNumber: | 2696392818 | ||||||||
| Practice Location | |||||||||
| Address1: | 955 S BAILEY AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH HAVEN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490909701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2696375271 | ||||||||
| FaxNumber: | 2696392818 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 11/30/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 5101007985 | MI | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3217497 T11 | 05 | MI | MEDICAID |