MEDICARE: GENESYS HILLSIDE BEHAVIORAL SERVICES

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	283Q00000X	Psychiatric Hospital	6801081184	MI

General Provider Information

NPI Number	:	1336498013
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GENESYS HILLSIDE BEHAVIORAL SERVICES

Provider Business Mailing Address
First Line	:	4396 MEADOWS AVE
Second Line	:
City	:	GRAND BLANC
State	:	MI
Zip	:	48439-8689
Country	:	US
Telephone Number	:	810-424-2400
Fax Number	:	810-579-7222

Provider Business Practice Location Address
First Line	:	4396 MEADOWS AVE
Second Line	:
City	:	GRAND BLANC
State	:	MI
Zip	:	48439-8689
Country	:	US
Telephone Number	:	810-513-2390
Fax Number	:	810-579-7222

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. PURNA SURAPANENI
Credential	:	M.D.
Telephone Number	:	810-424-2400

Provider Enumeration Date	:	09/10/2012
Last Update Date	:	09/10/2012

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