Healthcare Provider Details

I. General information

NPI: 1144549692
Provider Name (Legal Business Name): TATULYA TIWARI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2010
Last Update Date: 10/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 E. MEDICAL CENTER DR #B1F510K RAD: DIAGNOSTIC RADIOLOGY
ANN ARBOR MI
48109-5030
US

IV. Provider business mailing address

1500 E MEDICAL CENTER DRIVE UH B1D530
ANN ARBOR MI
48109-5030
US

V. Phone/Fax

Practice location:
  • Phone: 734-936-4338
  • Fax: 734-615-3506
Mailing address:
  • Phone: 734-647-4144
  • Fax: 734-615-1276

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number4301106929
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number11015479A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number0116023309
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: