MEDICARE: MICHIGAN BEHAVIORAL MEDICINE PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	103T00000X	Psychologist
2	104100000X	Social Worker
3	2084P0800X	Psychiatry Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	10487	OTHER	MA	BLUE CROSS NUMBER

General Provider Information

NPI Number	:	1144317116
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MICHIGAN BEHAVIORAL MEDICINE PLLC

Provider Business Mailing Address
First Line	:	2525 CROOKS RD
Second Line	:	SUITE #100
City	:	TROY
State	:	MI
Zip	:	48084-1426
Country	:	US
Telephone Number	:	248-731-7305
Fax Number	:

Provider Business Practice Location Address
First Line	:	2525 CROOKS RD
Second Line	:	SUITE #101
City	:	TROY
State	:	MI
Zip	:	48084-4733
Country	:	US
Telephone Number	:	248-731-7305
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	RENE JOSEPH
Credential	:
Telephone Number	:	248-703-1897

Provider Enumeration Date	:	10/09/2006
Last Update Date	:	05/28/2019

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