Provider Demographics
NPI:1144496860
Name:ASSOCIATED GENERAL PRACTICE NETWORK PLLC
Entity type:Organization
Organization Name:ASSOCIATED GENERAL PRACTICE NETWORK PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MS
Authorized Official - First Name:INDIRA
Authorized Official - Middle Name:
Authorized Official - Last Name:DESIKACHAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-231-8542
Mailing Address - Street 1:30345 RUSHMORE CIR
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:MI
Mailing Address - Zip Code:48025-1510
Mailing Address - Country:US
Mailing Address - Phone:248-231-8542
Mailing Address - Fax:248-485-6631
Practice Address - Street 1:11803 GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48204-1810
Practice Address - Country:US
Practice Address - Phone:313-491-5544
Practice Address - Fax:248-485-6631
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-02
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI11-0-H2-3914-0OtherBCBS
MI11-0-H2-3914-0OtherBCBS