Provider Demographics
NPI:1811633241
Name:REQUIEM, LLC
Entity type:Organization
Organization Name:REQUIEM, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:PIERRE
Authorized Official - Middle Name:CHARBEL
Authorized Official - Last Name:ATALLAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MS, MBA
Authorized Official - Phone:248-495-2438
Mailing Address - Street 1:145 S LIVERNOIS RD # 336
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48307-1837
Mailing Address - Country:US
Mailing Address - Phone:248-495-2438
Mailing Address - Fax:
Practice Address - Street 1:543 N MAIN ST STE 211
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48307-1485
Practice Address - Country:US
Practice Address - Phone:248-495-2438
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-09
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI20150804334789Medicaid
0931859OtherBCBS
F34995040OtherPTAN