Provider Demographics
NPI:1508964511
Name:OAKLAND GASTROENTEROLOGY ASSOCIATES, P.C.
Entity Type:Organization
Organization Name:OAKLAND GASTROENTEROLOGY ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGG
Authorized Official - Middle Name:
Authorized Official - Last Name:POLIDORI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-551-0900
Mailing Address - Street 1:3535 W 13 MILE RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-6770
Mailing Address - Country:US
Mailing Address - Phone:248-551-0900
Mailing Address - Fax:248-551-0905
Practice Address - Street 1:3535 W 13 MILE RD
Practice Address - Street 2:SUITE 202
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6770
Practice Address - Country:US
Practice Address - Phone:248-551-0900
Practice Address - Fax:248-551-0905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301044285207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI100F37143OtherBCBS AND BCN
MI4101048Medicaid
MI4310182Medicaid
MI2836211Medicaid
MI4257370Medicaid
MI3364901Medicaid
MI4258298Medicaid
MI4257380Medicaid
MI4340978Medicaid
MI4340940Medicaid
MI4592984Medicaid
MI2836230Medicaid
MI4318636Medicaid
MIF28208Medicare UPIN
MIC45037Medicare UPIN
MI4101048Medicaid
MI4258298Medicaid
MI3364901Medicaid
MI4310182Medicaid
MI2836211Medicaid