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:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:BIEDERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:248-471-8982
Mailing Address - Street 1:DEPT 203901
Mailing Address - Street 2:P O BOX 67000
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48267-0001
Mailing Address - Country:US
Mailing Address - Phone:248-471-8982
Mailing Address - Fax:248-471-9978
Practice Address - Street 1:28080 GRAND RIVER AVE
Practice Address - Street 2:SUITE 306
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48336-5966
Practice Address - Country:US
Practice Address - Phone:248-471-8982
Practice Address - Fax:248-471-9978
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-02
Last Update Date:2016-01-13
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