Healthcare Provider Details

I. General information

NPI: 1730386913
Provider Name (Legal Business Name): MANHAL W TOBIA M.D., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2007
Last Update Date: 10/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18161 W 12 MILE RD STE 2
LATHRUP VILLAGE MI
48076-2662
US

IV. Provider business mailing address

18161 W 12 MILE RD STE 2
LATHRUP VILLAGE MI
48076-2662
US

V. Phone/Fax

Practice location:
  • Phone: 248-552-1200
  • Fax: 248-552-1201
Mailing address:
  • Phone: 248-552-1200
  • Fax: 248-552-1201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number4301068505
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License NumberMT068505
License Number StateMI

VIII. Authorized Official

Name: MRS. MELINDA JOANNE SHAMOUN
Title or Position: OFFICE MANAGER
Credential:
Phone: 248-552-1200