Healthcare Provider Details

I. General information

NPI: 1114929791
Provider Name (Legal Business Name): GUAT SIA SY JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2005
Last Update Date: 11/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17000 HUBBARD DR SUITE 700
DEARBORN MI
48126-4258
US

IV. Provider business mailing address

17000 HUBBARD DR SUITE 700
DEARBORN MI
48126-4258
US

V. Phone/Fax

Practice location:
  • Phone: 313-271-2990
  • Fax: 313-271-1698
Mailing address:
  • Phone: 313-271-2990
  • Fax: 313-271-1698

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number4301040071
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number4301040071
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: