Provider Demographics
NPI:1154619849
Name:TABASSUM, RANA (MD)
Entity type:Individual
Prefix:
First Name:RANA
Middle Name:
Last Name:TABASSUM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 MEADOW CREEK CT
Mailing Address - Street 2:
Mailing Address - City:VERNON HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60061-2562
Mailing Address - Country:US
Mailing Address - Phone:248-952-1440
Mailing Address - Fax:
Practice Address - Street 1:6071 W OUTER DR
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-2624
Practice Address - Country:US
Practice Address - Phone:313-966-3250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-14
Last Update Date:2018-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI57735-20315P00000X
MI4301099130207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual DisabilitiesGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty