Healthcare Provider Details

I. General information

NPI: 1457589657
Provider Name (Legal Business Name): DEGARA, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2009
Last Update Date: 06/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 N PERRY ST EMERGENCY DEPARTMENT
PONTIAC MI
48342-2217
US

IV. Provider business mailing address

5249 RELIABLE PKWY
CHICAGO IL
60686-0001
US

V. Phone/Fax

Practice location:
  • Phone: 248-338-5332
  • Fax:
Mailing address:
  • Phone: 866-898-7139
  • Fax: 616-975-9827

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateMI

VIII. Authorized Official

Name: DR. TRESSA GARDNER
Title or Position: CEO
Credential: DO
Phone: 248-338-5339