Provider Demographics
NPI:1710988688
Name:TOLIA, KETAN (MD)
Entity Type:Individual
Prefix:
First Name:KETAN
Middle Name:
Last Name:TOLIA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:26850 PROVIDENCE PKWY
Mailing Address - Street 2:PMOB#200
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48374-1213
Mailing Address - Country:US
Mailing Address - Phone:248-465-3144
Mailing Address - Fax:248-465-3146
Practice Address - Street 1:22255 GREENFIELD
Practice Address - Street 2:400
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075
Practice Address - Country:US
Practice Address - Phone:248-465-4010
Practice Address - Fax:248-465-4011
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301054022207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI447791910Medicaid
MI447791910Medicaid
MI0F36477097Medicare PIN