Healthcare Provider Details

I. General information

NPI: 1225117492
Provider Name (Legal Business Name): INGRID JULIE YEO CHUA-MANALO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 12/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46325 W. TWELVE MILE RD. STE. 100
NOVI MI
48377-0000
US

IV. Provider business mailing address

29275 NORTHWESTERN HWY. STE. 100
SOUTHFIELD MI
48034-0000
US

V. Phone/Fax

Practice location:
  • Phone: 877-784-3667
  • Fax: 248-869-3982
Mailing address:
  • Phone: 877-784-3667
  • Fax: 248-869-3982

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number4301064281
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: