Basic Information
| Provider Information | |||||||||
| NPI: | 1730386913 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MANHAL W TOBIA M.D., P.C. | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 18161 W 12 MILE RD STE 2 | ||||||||
| Address2: | |||||||||
| City: | LATHRUP VILLAGE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480762662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485521200 | ||||||||
| FaxNumber: | 2485521201 | ||||||||
| Practice Location | |||||||||
| Address1: | 18161 W 12 MILE RD STE 2 | ||||||||
| Address2: | |||||||||
| City: | LATHRUP VILLAGE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480762662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485521200 | ||||||||
| FaxNumber: | 2485521201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2007 | ||||||||
| LastUpdateDate: | 10/17/2007 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SHAMOUN | ||||||||
| AuthorizedOfficialFirstName: | MELINDA | ||||||||
| AuthorizedOfficialMiddleName: | JOANNE | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2485521200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 305R00000X | MT068505 | MI | N | Managed Care Organizations | Preferred Provider Organization | 173000000X | 4301068505 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Legal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1730386913 | 01 | MI | 06338982 | OTHER | 1730386913 | 01 | MI | GROUP NPI | OTHER |