=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487192993
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PULMONARY, INTERNAL AND EMERGENCY MEDICINE AND RADIOLOGY ASSO
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2017
-----------------------------------------------------
Last Update Date | 02/10/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 26699 W 12 MILE RD SUITE 101
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48034-1578
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-358-4783
-----------------------------------------------------
Fax | 248-359-1491
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 26699 W 12 MILE RD SUITE 101
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48034-1578
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-358-4783
-----------------------------------------------------
Fax | 248-359-1491
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | SHYAM MAHESH
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 248-358-4783
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RP1001X
-----------------------------------------------------
Taxonomy Name | Pulmonary Disease Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------