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General NPI Number Information
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NPI Number | 1760814289
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Entity Type | Organization
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Legal Business Name | CENTER FOR INDIVIDUALIZED MEDICINE PLLC
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Dates
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Enumeration Date | 08/07/2013
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Last Update Date | 08/07/2013
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Provider Practice Location Address
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Address Line | 1404 BIDDLE AVE
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City | WYANDOTTE
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State | MI
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Zip | 48192-3706
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Country | US
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Telephone | 734-624-8000
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Fax | 734-326-1443
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Provider Business Mailing Address
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Address Line | PO BOX 251921
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City | WEST BLOOMFIELD
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State | MI
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Zip | 48325-1921
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Country | US
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Telephone | 734-324-8000
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Fax | 734-324-0993
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Authorized Official
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Title or Position | OWNER
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Name | SURJIT S MAHAL
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Credential | MD
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Telephone | 734-324-8000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0804X
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Taxonomy Name | Child & Adolescent Psychiatry Physician
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License Number | 4301046425
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License Number State | MI
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