Healthcare Provider Details

I. General information

NPI: 1972697688
Provider Name (Legal Business Name): TOLIA PEDIATRIC GI CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 06/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22250 PROVIDENCE DR SUITE 400
SOUTHFIELD MI
48075-4825
US

IV. Provider business mailing address

22250 PROVIDENCE DR SUITE 400
SOUTHFIELD MI
48075-4825
US

V. Phone/Fax

Practice location:
  • Phone: 248-865-0030
  • Fax: 248-865-0034
Mailing address:
  • Phone: 248-865-0030
  • Fax: 248-865-0034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number4301037974
License Number StateMI

VIII. Authorized Official

Name: DR. VASUNDHARA TOLIA
Title or Position: OWNER/PHYSICIAN
Credential: MD
Phone: 248-865-0030