Provider Demographics
NPI:1104247899
Name:WOODWARD GASTROENTEROLOGY PC
Entity type:Organization
Organization Name:WOODWARD GASTROENTEROLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TUSAR
Authorized Official - Middle Name:KISHORE
Authorized Official - Last Name:DESAI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-229-8354
Mailing Address - Street 1:1257 CLUB DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48302-0907
Mailing Address - Country:US
Mailing Address - Phone:248-229-8354
Mailing Address - Fax:
Practice Address - Street 1:1695 12 MILE RD
Practice Address - Street 2:SUITE 220
Practice Address - City:BERKLEY
Practice Address - State:MI
Practice Address - Zip Code:48072-2182
Practice Address - Country:US
Practice Address - Phone:248-229-8354
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-23
Last Update Date:2014-03-07
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
MIE76131Medicare UPIN