=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528453487
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MICHIGAN CLINICAL RESEARCH INSTITUTE PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/30/2015
-----------------------------------------------------
Last Update Date | 03/30/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3001 PLYMOUTH RD
-----------------------------------------------------
City | ANN ARBOR
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48105-3205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-834-8954
-----------------------------------------------------
Fax | 734-780-7506
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3001 PLYMOUTH RD
-----------------------------------------------------
City | ANN ARBOR
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48105-3205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-834-8954
-----------------------------------------------------
Fax | 734-780-7506
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. RAJAPRABHAKARAN RAJARETHINAM
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 734-846-2898
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 4301064033
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------