Provider Demographics
NPI:1730417288
Name:AGE MANAGEMENT AND HORMONE BALANCE CENTER
Entity type:Organization
Organization Name:AGE MANAGEMENT AND HORMONE BALANCE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INTERNIST-MANAGING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PIYUSH
Authorized Official - Middle Name:
Authorized Official - Last Name:BHATNAGAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-808-2695
Mailing Address - Street 1:1787 GRAND RIDGE CT NE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-7042
Mailing Address - Country:US
Mailing Address - Phone:616-808-2695
Mailing Address - Fax:616-808-2697
Practice Address - Street 1:1787 GRAND RIDGE CT NE
Practice Address - Street 2:SUITE 202
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-7042
Practice Address - Country:US
Practice Address - Phone:616-808-2695
Practice Address - Fax:616-808-2697
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-20
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301076867207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty