Healthcare Provider Details

I. General information

NPI: 1295383909
Provider Name (Legal Business Name): MICHIGAN PSYCHIATRIC & PRIMARY CARE CLINIC, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2019
Last Update Date: 01/03/2024
Certification Date: 07/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 W LAKE LANSING RD
EAST LANSING MI
48823-8526
US

IV. Provider business mailing address

702 W LAKE LANSING RD
EAST LANSING MI
48823-8526
US

V. Phone/Fax

Practice location:
  • Phone: 517-332-5342
  • Fax:
Mailing address:
  • Phone: 517-332-5342
  • Fax: 517-316-2893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: THAM N DOAN
Title or Position: MANAGER
Credential: NP
Phone: 517-332-5342