Provider Demographics
NPI:1730343930
Name:REZA KERMANSHAHI, TAHER (MD)
Entity type:Individual
Prefix:
First Name:TAHER
Middle Name:
Last Name:REZA KERMANSHAHI
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 1:24 FRANK LLOYD WRIGHT DRIVE
Mailing Address - Street 2:SUITE J2000
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105
Mailing Address - Country:US
Mailing Address - Phone:313-593-7963
Mailing Address - Fax:313-593-7143
Practice Address - Street 1:IHA PATHOLOGY & LABORATORY MANAGEMENT
Practice Address - Street 2:5301 E HURON RIVER DRIVE
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197
Practice Address - Country:US
Practice Address - Phone:734-712-3161
Practice Address - Fax:734-712-2244
Is Sole Proprietor?:No
Enumeration Date:2008-07-16
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2014-01236207ZP0102X
SCMD36887207ZP0102X
MO2011037784207ZP0102X
MI4301108473207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology