Healthcare Provider Details

I. General information

NPI: 1902896749
Provider Name (Legal Business Name): GARY M HOLLANDER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 02/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 N PONTIAC TRL
WALLED LAKE MI
48390-3443
US

IV. Provider business mailing address

620 N PONTIAC TRL
WALLED LAKE MI
48390-3443
US

V. Phone/Fax

Practice location:
  • Phone: 248-624-4511
  • Fax: 248-624-4408
Mailing address:
  • Phone: 248-624-4511
  • Fax: 248-624-4408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number5101012793
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: