Healthcare Provider Details

I. General information

NPI: 1609362375
Provider Name (Legal Business Name): THEORIA MEDICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2018
Last Update Date: 07/23/2025
Certification Date: 07/23/2025
Deactivation Date: 08/09/2021
Reactivation Date: 08/11/2021

III. Provider practice location address

41800 W 11 MILE RD STE 109
NOVI MI
48375-1818
US

IV. Provider business mailing address

41800 W 11 MILE RD STE 109
NOVI MI
48375-1818
US

V. Phone/Fax

Practice location:
  • Phone: 248-860-4634
  • Fax: 248-282-5044
Mailing address:
  • Phone: 248-860-4634
  • Fax: 248-282-5044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 8
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JUSTIN P DI REZZE
Title or Position: OWNER/PHYSICIAN
Credential: MD
Phone: 248-860-4634