Provider Demographics
NPI:1871958744
Name:MADHOUN, SABA (PA)
Entity type:Individual
Prefix:
First Name:SABA
Middle Name:
Last Name:MADHOUN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15150 FORT
Mailing Address - Street 2:
Mailing Address - City:SOUTHGATE
Mailing Address - State:MI
Mailing Address - Zip Code:48195
Mailing Address - Country:US
Mailing Address - Phone:734-282-4800
Mailing Address - Fax:734-282-9302
Practice Address - Street 1:15150 FORT ST
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-1302
Practice Address - Country:US
Practice Address - Phone:734-282-4800
Practice Address - Fax:734-282-9302
Is Sole Proprietor?:No
Enumeration Date:2015-12-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI5601008284363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI38-2546610OtherBLUE CROSS BLUE SHIELD
MI38-2546610Medicaid