Healthcare Provider Details

I. General information

NPI: 1306937339
Provider Name (Legal Business Name): BAL K GUPTA MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 08/22/2020
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 TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number4301037633
License Number StateMI

VIII. Authorized Official

Name: DR. BAL KRISHAN GUPTA
Title or Position: PRESIDENT
Credential: MD
Phone: 586-573-5300