Provider Demographics
NPI:1144317116
Name:MICHIGAN BEHAVIORAL MEDICINE PLLC
Entity type:Organization
Organization Name:MICHIGAN BEHAVIORAL MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:RENE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOSEPH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-703-1897
Mailing Address - Street 1:2525 CROOKS RD
Mailing Address - Street 2:SUITE #100
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-1426
Mailing Address - Country:US
Mailing Address - Phone:248-731-7305
Mailing Address - Fax:
Practice Address - Street 1:2525 CROOKS RD
Practice Address - Street 2:SUITE #101
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-4733
Practice Address - Country:US
Practice Address - Phone:248-731-7305
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-09
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA10487OtherBLUE CROSS NUMBER
MIOP 25450Medicare ID - Type Unspecified