MEDICARE: AYESHA M TAJ D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2080A0000X	Pediatric Adolescent Medicine Physician	5101013698	MI

General Provider Information

NPI Number	:	1801858733
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AYESHA M TAJ D.O.

Provider Business Mailing Address
First Line	:	1749 IMAN RD
Second Line	:
City	:	CANTON
State	:	MI
Zip	:	48188-2229
Country	:	US
Telephone Number	:	734-255-7021
Fax Number	:

Provider Business Practice Location Address
First Line	:	1600 S CANTON CENTER RD
Second Line	:	SUITE 200
City	:	CANTON
State	:	MI
Zip	:	48188-1992
Country	:	US
Telephone Number	:	734-398-8675
Fax Number	:	734-398-8670

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/05/2006
Last Update Date	:	07/08/2007

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