=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114219227
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTH MICHIGAN PSYCHIATRIC SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2011
-----------------------------------------------------
Last Update Date | 02/16/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5390 LOVERS LN THIRD FLOOR
-----------------------------------------------------
City | PORTAGE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-381-6950
-----------------------------------------------------
Fax | 269-381-6954
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5930 LOVERS LN THIRD FLOOR
-----------------------------------------------------
City | PORTAGE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49002-1673
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-381-6950
-----------------------------------------------------
Fax | 269-381-6954
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | RUQIYA TAREEN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 269-381-6950
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 4301078095
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------