Provider Demographics
NPI:1528102571
Name:M. REDWAN KUBAISI MD PC
Entity type:Organization
Organization Name:M. REDWAN KUBAISI MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:M.
Authorized Official - Middle Name:REDWAN
Authorized Official - Last Name:KUBAISI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-383-7830
Mailing Address - Street 1:8449 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:ALLEN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48101-1594
Mailing Address - Country:US
Mailing Address - Phone:313-383-7830
Mailing Address - Fax:313-383-7831
Practice Address - Street 1:8449 PARK AVE
Practice Address - Street 2:
Practice Address - City:ALLEN PARK
Practice Address - State:MI
Practice Address - Zip Code:48101-1594
Practice Address - Country:US
Practice Address - Phone:313-383-7830
Practice Address - Fax:313-383-7831
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========OtherTAX IDENTIFICATION