Individual
GINA FUNDARO
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
4100 JOHN R ST, DETROIT, MI 48201-2013
(313) 745-8042
(313) 745-2314
Mailing address
24601 NORTHWESTERN HWY, SOUTHFIELD, MI 48075-2473
(248) 827-4580
(248) 827-7663
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
Primary
4301074481
MI
208D00000X
General Practice Physician
4301074481
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
7005261920
BCBS
MI
Enumeration date
10/03/2005
Last updated
10/07/2020
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