=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336498013
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GENESYS HILLSIDE BEHAVIORAL SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/10/2012
-----------------------------------------------------
Last Update Date | 09/10/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4396 MEADOWS AVE
-----------------------------------------------------
City | GRAND BLANC
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48439-8689
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-513-2390
-----------------------------------------------------
Fax | 810-579-7222
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4396 MEADOWS AVE
-----------------------------------------------------
City | GRAND BLANC
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48439-8689
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-424-2400
-----------------------------------------------------
Fax | 810-579-7222
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. PURNA SURAPANENI
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 810-424-2400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 283Q00000X
-----------------------------------------------------
Taxonomy Name | Psychiatric Hospital
-----------------------------------------------------
License Number | 6801081184
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------