Healthcare Provider Details

I. General information

NPI: 1225041353
Provider Name (Legal Business Name): BAL KRISHAN GUPTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 04/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11900 E TWELVE MILE RD SUITE 111
WARREN MI
48093-3472
US

IV. Provider business mailing address

11900 E TWELVE MILE RD SUITE 111
WARREN MI
48093-3472
US

V. Phone/Fax

Practice location:
  • Phone: 586-573-5300
  • Fax: 586-573-5304
Mailing address:
  • Phone: 586-573-5300
  • Fax: 586-573-5304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License Number4301037633
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number4301037633
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: