=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225061419
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANANDA MEDICAL CLINIC AND HEALING CENTER PLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/09/2006
-----------------------------------------------------
Last Update Date | 08/06/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2200 MONROE ST
-----------------------------------------------------
City | DEARBORN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48124-3058
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-565-8700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 44548 SPRING HILL RD
-----------------------------------------------------
City | NORTHVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48168-4367
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-565-8700
-----------------------------------------------------
Fax | 313-565-9400
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MADHU GUPTA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 313-565-8700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------