MEDICARE: INTERNAL MEDICINE AND PEDIATRICS OF BLOOMFIELD PC

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	208000000X	Pediatrics Physician		MI
2	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1932227873
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTERNAL MEDICINE AND PEDIATRICS OF BLOOMFIELD PC

Provider Business Mailing Address
First Line	:	1109 W LONG LAKE RD
Second Line	:
City	:	BLOOMFIELD HILLS
State	:	MI
Zip	:	48302-1964
Country	:	US
Telephone Number	:	248-723-2400
Fax Number	:

Provider Business Practice Location Address
First Line	:	1109 W LONG LAKE RD
Second Line	:
City	:	BLOOMFIELD HILLS
State	:	MI
Zip	:	48302-1964
Country	:	US
Telephone Number	:	248-723-2400
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	STEVE KALLABAT
Credential	:	MD
Telephone Number	:	248-723-2400

Provider Enumeration Date	:	03/27/2007
Last Update Date	:	11/16/2023

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