Healthcare Provider Details

I. General information

NPI: 1386639813
Provider Name (Legal Business Name): AMITABHA BANERJEE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/12/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1125 S LINDEN RD SUITE 500
FLINT MI
48532-4073
US

IV. Provider business mailing address

G1125 SOUTH LINDEN RD SUITE 500
FLINT MI
48532
US

V. Phone/Fax

Practice location:
  • Phone: 810-230-2323
  • Fax: 810-732-3199
Mailing address:
  • Phone: 810-230-2323
  • Fax: 810-732-3199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301037964
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: