Provider Demographics
NPI:1609362375
Name:THEORIA MEDICAL
Entity Type:Organization
Organization Name:THEORIA MEDICAL
Other - Org Name:JUSTIN P DIREZZE MD SOLE MBR
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:P
Authorized Official - Last Name:DI REZZE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-860-4634
Mailing Address - Street 1:41800 W 11 MILE RD STE 109
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-1818
Mailing Address - Country:US
Mailing Address - Phone:248-860-4634
Mailing Address - Fax:248-282-5044
Practice Address - Street 1:41800 W 11 MILE RD STE 109
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-1818
Practice Address - Country:US
Practice Address - Phone:248-860-4634
Practice Address - Fax:248-282-5044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-06
Last Update Date:2022-08-22
Deactivation Date:2021-08-09
Deactivation Code:
Reactivation Date:2021-08-11
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0411248Medicaid