Provider Demographics
NPI:1750573721
Name:TISA K TESTAI DO.,PC
Entity type:Organization
Organization Name:TISA K TESTAI DO.,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:TISA
Authorized Official - Middle Name:K
Authorized Official - Last Name:TESTAI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:248-651-9700
Mailing Address - Street 1:1460 WALTON BLVD
Mailing Address - Street 2:SUITE 206
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48309-1768
Mailing Address - Country:US
Mailing Address - Phone:248-651-9700
Mailing Address - Fax:248-651-9701
Practice Address - Street 1:1460 WALTON BLVD
Practice Address - Street 2:SUITE 206
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48309-1768
Practice Address - Country:US
Practice Address - Phone:248-651-9700
Practice Address - Fax:248-651-9701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-14
Last Update Date:2011-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MITG011081207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P03340Medicare PIN
MIF69602Medicare UPIN