=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184670564
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIDWEST CENTER FOR SLEEP DISORDERS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/26/2006
-----------------------------------------------------
Last Update Date | 01/13/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10415 GRAND RIVER RD STE 500
-----------------------------------------------------
City | BRIGHTON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48116-6535
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-225-7595
-----------------------------------------------------
Fax | 810-225-7597
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 101 E SPICERVILLE HWY
-----------------------------------------------------
City | EATON RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48827-1919
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-663-9469
-----------------------------------------------------
Fax | 517-663-9470
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-OWNER
-----------------------------------------------------
Name | DR. ASHOK K GUPTA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 517-663-9469
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RS0012X
-----------------------------------------------------
Taxonomy Name | Sleep Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number | AG048680
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RS0012X
-----------------------------------------------------
Taxonomy Name | Sleep Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number | CG043420
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207RS0012X
-----------------------------------------------------
Taxonomy Name | Sleep Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number | AA058590
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 261QS1200X
-----------------------------------------------------
Taxonomy Name | Sleep Disorder Diagnostic Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------