Basic Information
| Provider Information | |||||||||
| NPI: | 1275520512 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FUNDARO | ||||||||
| FirstName: | GINA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24601 NORTHWESTERN HWY | ||||||||
| Address2: | |||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480752473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488274580 | ||||||||
| FaxNumber: | 2488277663 | ||||||||
| Practice Location | |||||||||
| Address1: | 4100 JOHN R ST | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482012013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3137458042 | ||||||||
| FaxNumber: | 3137452314 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2005 | ||||||||
| LastUpdateDate: | 10/07/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 4301074481 | MI | N | Allopathic & Osteopathic Physicians | General Practice | 2085R0202X | 4301074481 | MI | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 7005261920 | 01 | MI | BCBS | OTHER |