=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730545310
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RODAS MD PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2016
-----------------------------------------------------
Last Update Date | 01/12/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19928 EDINBERG DR
-----------------------------------------------------
City | MACOMB
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48044-2150
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-485-7777
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19928 EDINBERG DR
-----------------------------------------------------
City | MACOMB
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48044-2150
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-485-7777
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. TESFAMARIAM O METIKU
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 313-485-7777
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 4301092621
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------