=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720030968
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | FEDOR OPOCHINSKY
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2006
-----------------------------------------------------
Last Update Date | 03/17/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 215 NORTH AVE
-----------------------------------------------------
City | MOUNT CLEMENS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48043-1716
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-466-9939
-----------------------------------------------------
Fax | 586-466-9956
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 7987
-----------------------------------------------------
City | BLOOMFIELD HILLS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48302-7987
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-466-9939
-----------------------------------------------------
Fax | 586-466-9956
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 4301063169
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------