Basic Information
| Provider Information | |||||||||
| NPI: | 1104141712 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAKDASH | ||||||||
| FirstName: | TARIF | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26901 BEAUMONT BLVD STE 3D | ||||||||
| Address2: | |||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480333849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9475221860 | ||||||||
| FaxNumber: | 9475220307 | ||||||||
| Practice Location | |||||||||
| Address1: | 3555 W 13 MILE RD STE N120A | ||||||||
| Address2: | |||||||||
| City: | ROYAL OAK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480736710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485510487 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2010 | ||||||||
| LastUpdateDate: | 06/18/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 12298 | MT | N | Allopathic & Osteopathic Physicians | Pediatrics | 2084N0400X | 63034 | WI | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0402X | 24539 | MS | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology with Special Qualifications in Child Neurology | 2084N0402X | 63034 | WI | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology with Special Qualifications in Child Neurology | 2084N0600X | 63034 | WI | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Clinical Neurophysiology | 208000000X | 4301055614 | MI | Y | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 2012014535 | MO | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 431560263 | 01 | MO | TRICARE | OTHER | P01110482 | 01 | MO | RR MCR | OTHER | 1104141712 | 05 | MO | MEDICAID | 12298 | 01 | MT | LICENSE | OTHER | 192753001 | 05 | AR | MEDICAID | 05127841 | 05 | MS | MEDICAID | 200435170A | 05 | OK | MEDICAID |