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General NPI Number Information
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NPI Number | 1972527026
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Entity Type | Organization
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Legal Business Name | DIVI MD PC
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Dates
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Enumeration Date | 07/26/2006
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Last Update Date | 12/14/2009
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Provider Practice Location Address
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Address Line | 20755 GREENFIELD RD STE #1004
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City | SOUTHFIELD
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State | MI
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Zip | 48075-5403
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Country | US
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Telephone | 248-424-5090
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Fax | 248-424-5091
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Provider Business Mailing Address
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Address Line | 20755 GREENFIELD ROAD STE # 1004
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City | SOUTHFIELD
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State | MI
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Zip | 48075-5411
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Country | US
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Telephone | 248-424-5090
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Fax | 248-424-5091
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Authorized Official
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Title or Position | OWNER/PRESIDENT
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Name | THULASI S DIVI
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Credential | MD
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Telephone | 248-528-1555
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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 | 4301062122
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License Number State | MI
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