=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407600117
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIDWEST PSYCHIATRY GROUP PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/17/2024
-----------------------------------------------------
Last Update Date | 09/10/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3892 ANDOVER AVE
-----------------------------------------------------
City | AUBURN HILLS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48326-3031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-495-8658
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 43313 WOODWARD AVE # 1418
-----------------------------------------------------
City | BLOOMFIELD HILLS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48302-5007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-397-4753
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | MANINDERPAL DHILLON
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 248-495-8658
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------