Provider Demographics
NPI:1316919616
Name:SOUTH OAKLAND GASTROENTEROLOGY ASSOCIATES PC
Entity type:Organization
Organization Name:SOUTH OAKLAND GASTROENTEROLOGY ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JOLIAN
Authorized Official - Middle Name:SAM
Authorized Official - Last Name:KATHAWA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-579-9220
Mailing Address - Street 1:PO BOX 72737
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44192-0002
Mailing Address - Country:US
Mailing Address - Phone:248-579-9220
Mailing Address - Fax:248-426-7350
Practice Address - Street 1:23133 ORCHARD LAKE RD STE 200
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MI
Practice Address - Zip Code:48336-3279
Practice Address - Country:US
Practice Address - Phone:248-579-9220
Practice Address - Fax:248-426-7350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-02
Last Update Date:2025-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101006198207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1316919616Medicaid
MI1316919616Medicaid