Provider Demographics
NPI:1376764019
Name:NORTH OAKLAND GASTROENTEROLOGY CLINIC PC
Entity Type:Organization
Organization Name:NORTH OAKLAND GASTROENTEROLOGY CLINIC PC
Other - Org Name:PREMIER PATHOLOGY (DBA)
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KAMBIZ
Authorized Official - Middle Name:
Authorized Official - Last Name:BRAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-844-2700
Mailing Address - Street 1:PO BOX 81087
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48308-1087
Mailing Address - Country:US
Mailing Address - Phone:248-844-2700
Mailing Address - Fax:248-852-0806
Practice Address - Street 1:75 BARCLAY CIRCLE
Practice Address - Street 2:SUITE 205
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307-0020
Practice Address - Country:US
Practice Address - Phone:248-844-2700
Practice Address - Fax:248-852-0806
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTH OAKLAND GASTROENTEROLOGY CLINIC, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-01
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIKB063477174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI306300410Medicaid
MIE42699Medicare UPIN
MI0P11750Medicare PIN