Basic Information
| Provider Information | |||||||||
| NPI: | 1710988688 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TOLIA | ||||||||
| FirstName: | KETAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26850 PROVIDENCE PKWY | ||||||||
| Address2: | PMOB#200 | ||||||||
| City: | NOVI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483741213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2484653144 | ||||||||
| FaxNumber: | 2484653146 | ||||||||
| Practice Location | |||||||||
| Address1: | 22255 GREENFIELD | ||||||||
| Address2: | 400 | ||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48075 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2484654010 | ||||||||
| FaxNumber: | 2484654011 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2005 | ||||||||
| LastUpdateDate: | 08/13/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301054022 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 447791910 | 05 | MI | MEDICAID |