Basic Information
| Provider Information | |||||||||
| NPI: | 1851718092 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DERYAVOUSH | ||||||||
| FirstName: | TARA | ||||||||
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| Credential: | D.O | ||||||||
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| Mailing Information | |||||||||
| Address1: | 50505 SCHOENHERR RD STE 340 | ||||||||
| Address2: | |||||||||
| City: | SHELBY TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483153140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867318400 | ||||||||
| FaxNumber: | 5867318406 | ||||||||
| Practice Location | |||||||||
| Address1: | 133 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MOUNT CLEMENS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480432308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5864681600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2014 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 5101020870 | MI | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 5101020870 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.