Healthcare Provider Details

I. General information

NPI: 1134203896
Provider Name (Legal Business Name): COMMERCE PSYCHIATRIC SERVICES PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 07/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 NORTH POND DRIVE SUITE 6
WALLED LAKE MI
48390
US

IV. Provider business mailing address

55 NORTH POND DRIVE SUITE 6
WALLED LAKE MI
48390
US

V. Phone/Fax

Practice location:
  • Phone: 248-669-1900
  • Fax: 248-669-1925
Mailing address:
  • Phone: 248-669-1900
  • Fax: 248-669-1925

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number StateMI

VIII. Authorized Official

Name: DR. BRUCE LELAND ROTH
Title or Position: OWNER
Credential:
Phone: 248-360-6102