Healthcare Provider Details

I. General information

NPI: 1780686469
Provider Name (Legal Business Name): GUAT SY JR MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2005
Last Update Date: 08/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17000 HUBBARD DR STE 700
DEARBORN MI
48126-4205
US

IV. Provider business mailing address

17000 HUBBARD DR STE 700
DEARBORN MI
48126-4205
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: DR. GUAT SIA SY JR.
Title or Position: PRESIDENT
Credential: MD
Phone: 313-271-2990