Provider Demographics
NPI:1902105463
Name:ALTABAQCHALI, SAYF M (MD)
Entity Type:Individual
Prefix:
First Name:SAYF
Middle Name:M
Last Name:ALTABAQCHALI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-1915
Mailing Address - Country:US
Mailing Address - Phone:551-996-3880
Mailing Address - Fax:551-996-0949
Practice Address - Street 1:205 N EAST AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1753
Practice Address - Country:US
Practice Address - Phone:517-205-4800
Practice Address - Fax:313-876-1305
Is Sole Proprietor?:No
Enumeration Date:2011-03-23
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.207011207RC0000X
390200000X
MI4301099234207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02356553Medicaid
LA2370049Medicaid
LA367049YH3UMedicare PIN