Provider Demographics
NPI:1417948357
Name:TALIA, GHALIB Y (MD)
Entity Type:Individual
Prefix:
First Name:GHALIB
Middle Name:Y
Last Name:TALIA
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 1:44555 WOODWARD AVE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48341-5031
Mailing Address - Country:US
Mailing Address - Phone:246-338-4040
Mailing Address - Fax:248-858-3871
Practice Address - Street 1:44555 WOODWARD AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-5031
Practice Address - Country:US
Practice Address - Phone:246-338-4040
Practice Address - Fax:248-858-3871
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-31
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI044127208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2806367791OtherBLUE SHIELD
MI1552573Medicaid
MI0632732Medicare ID - Type Unspecified
A76087Medicare UPIN