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General NPI Number Information
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NPI Number | 1417001660
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Entity Type | Organization
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Legal Business Name | SOUTHEAST MICHIGAN MEDICAL ASSOCIATES PC
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Dates
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Enumeration Date | 01/23/2007
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Last Update Date | 02/21/2017
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Provider Practice Location Address
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Address Line | 18451 W 12 MILE RD STE 200
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City | LATHRUP VILLAGE
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State | MI
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Zip | 48076-2644
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Country | US
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Telephone | 248-827-7612
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Fax | 248-827-7615
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Provider Business Mailing Address
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Address Line | 18451 W 12 MILE RD STE 200
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City | LATHRUP VILLAGE
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State | MI
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Zip | 48076-2644
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Country | US
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Telephone | 248-827-7612
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Fax | 248-827-7615
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Authorized Official
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Title or Position | PRESIDENT
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Name | ASHOK KUMAR BANSAL
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Credential | M.D.
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Telephone | 248-827-7612
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 4301057441
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License Number State | MI
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