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General NPI Number Information
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NPI Number | 1164186946
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Entity Type | Organization
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Legal Business Name | THEORIA MEDICAL
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Dates
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Enumeration Date | 10/27/2021
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Last Update Date | 03/14/2022
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Provider Practice Location Address
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Address Line | 6247 GRAND RIVER RD STE 400
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City | BRIGHTON
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State | MI
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Zip | 48114-5326
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Country | US
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Telephone | 810-215-7177
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Fax | 313-217-3334
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Provider Business Mailing Address
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Address Line | 41800 W 11 MILE RD STE 109
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City | NOVI
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State | MI
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Zip | 48375-1818
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | JUSTIN DI REZZE
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Credential | MD
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Telephone | 313-610-8402
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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