Healthcare Provider Details

I. General information

NPI: 1174815195
Provider Name (Legal Business Name): GUPTA ENT CENTER WEST, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2011
Last Update Date: 09/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33200 W 14 MILE RD STE 240
WEST BLOOMFIELD MI
48322-3563
US

IV. Provider business mailing address

32121 WOODWARD AVE STE 203
ROYAL OAK MI
48073-6237
US

V. Phone/Fax

Practice location:
  • Phone: 248-539-9060
  • Fax: 248-539-9202
Mailing address:
  • Phone: 248-549-9035
  • Fax: 248-549-9407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332S00000X
TaxonomyHearing Aid Equipment
License Number4301062010
License Number StateMI

VIII. Authorized Official

Name: DR. ANIL K GUPTA
Title or Position: OWNER
Credential: MD
Phone: 248-549-9035