Provider Demographics
NPI:1063625671
Name:YASSIR ATTALLA PLLC
Entity type:Organization
Organization Name:YASSIR ATTALLA PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:YASSIR
Authorized Official - Middle Name:A
Authorized Official - Last Name:ATTALLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-399-3477
Mailing Address - Street 1:15450 NORTHLINE RD STE 102
Mailing Address - Street 2:
Mailing Address - City:SOUTHGATE
Mailing Address - State:MI
Mailing Address - Zip Code:48195-2490
Mailing Address - Country:US
Mailing Address - Phone:734-720-7270
Mailing Address - Fax:734-288-0934
Practice Address - Street 1:15450 NORTHLINE RD STE 102
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-2490
Practice Address - Country:US
Practice Address - Phone:734-282-2020
Practice Address - Fax:734-282-2002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIYA048664207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4995674Medicaid
MI0P43510001Medicare ID - Type Unspecified
MI4995674Medicaid