Healthcare Provider Details

I. General information

NPI: 1164671327
Provider Name (Legal Business Name): HARDIK BHANSALI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2008
Last Update Date: 10/01/2020
Certification Date: 10/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2799 W GRAND BLVD
DETROIT MI
48202-2608
US

IV. Provider business mailing address

55 WHITCHER ST NE STE 350
MARIETTA GA
30060-1129
US

V. Phone/Fax

Practice location:
  • Phone: 313-916-8144
  • Fax:
Mailing address:
  • Phone: 770-424-6893
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberME131123
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number84150
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: