Provider Demographics
NPI:1164524492
Name:GOLLADAY, EUSTACE S (MD)
Entity Type:Individual
Prefix:
First Name:EUSTACE
Middle Name:S
Last Name:GOLLADAY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3621 S STATE ST
Mailing Address - Street 2:700 KMS PLACE
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108
Mailing Address - Country:US
Mailing Address - Phone:734-936-2047
Mailing Address - Fax:
Practice Address - Street 1:1500 EAST MEDICAL CENTER DR
Practice Address - Street 2:3RD FLOOR MOTT HOSPITAL RM 3970
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109-0245
Practice Address - Country:US
Practice Address - Phone:734-764-4151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301066654208600000X, 2086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered208600000XAllopathic & Osteopathic PhysiciansSurgery
Not Answered2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3214332Medicaid
MI3214332Medicaid