Healthcare Provider Details

I. General information

NPI: 1144496860
Provider Name (Legal Business Name): ASSOCIATED GENERAL PRACTICE NETWORK PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2008
Last Update Date: 10/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11803 GRAND RIVER AVE
DETROIT MI
48204-1810
US

IV. Provider business mailing address

30345 RUSHMORE CIR
FRANKLIN MI
48025-1510
US

V. Phone/Fax

Practice location:
  • Phone: 313-491-5544
  • Fax: 248-485-6631
Mailing address:
  • Phone: 248-231-8542
  • Fax: 248-485-6631

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. INDIRA DESIKACHAR
Title or Position: MEMBER
Credential:
Phone: 248-231-8542