=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427167378
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHUJA HAQUE M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2006
-----------------------------------------------------
Last Update Date | 08/27/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4646 JOHN R STREET 11MH
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48201-1916
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-576-3373
-----------------------------------------------------
Fax | 313-576-1091
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4646 JOHN R ST 11MH
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48201-1916
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-576-3373
-----------------------------------------------------
Fax | 313-576-1091
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0805X
-----------------------------------------------------
Taxonomy Name | Geriatric Psychiatry Physician
-----------------------------------------------------
License Number | 4301055826
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 4301055826
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------