Healthcare Provider Details

I. General information

NPI: 1689942682
Provider Name (Legal Business Name): TRANSFORMATION MEDICAL SERVICES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2011
Last Update Date: 12/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21415 CIVIC CENTER DR SUITE 111
SOUTHFIELD MI
48076-3909
US

IV. Provider business mailing address

21415 CIVIC CENTER DR SUITE 111
SOUTHFIELD MI
48076-3909
US

V. Phone/Fax

Practice location:
  • Phone: 248-356-1111
  • Fax:
Mailing address:
  • Phone: 248-356-1111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number5101015861
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number5101015861
License Number StateMI

VIII. Authorized Official

Name: DR. ADDISON REEDE TARR
Title or Position: PRESIDENT AND CEO
Credential: D.O.
Phone: 714-225-8665