MEDICARE: MICHIGAN PSYCIATRIC & BEHAVIORAL ASSOCIATES PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	ON34080	OTHER	MI	MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	260Z910350	OTHER	MI	BCBS

General Provider Information

NPI Number	:	1326194168
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MICHIGAN PSYCIATRIC & BEHAVIORAL ASSOCIATES PC

Provider Business Mailing Address
First Line	:	690 S TRUMBULL ST
Second Line	:
City	:	BAY CITY
State	:	MI
Zip	:	48708-7656
Country	:	US
Telephone Number	:	989-922-4900
Fax Number	:	989-922-4911

Provider Business Practice Location Address
First Line	:	690 S TRUMBULL ST
Second Line	:
City	:	BAY CITY
State	:	MI
Zip	:	48708-7656
Country	:	US
Telephone Number	:	989-922-4900
Fax Number	:	989-922-4911

Authorized Official
Title or Position	:	CEO
Name	:	DR. KISHORE KONDAPANENI
Credential	:	MD
Telephone Number	:	989-922-4900

Provider Enumeration Date	:	01/26/2007
Last Update Date	:	03/22/2012

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