Provider Demographics
NPI:1033393442
Name:BADDIGAM FAMILY PSYCHIATRIC ASSOC
Entity Type:Organization
Organization Name:BADDIGAM FAMILY PSYCHIATRIC ASSOC
Other - Org Name:PSYCHOLOGY GROUP
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PRAMEELA
Authorized Official - Middle Name:
Authorized Official - Last Name:BADDIGAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-263-6812
Mailing Address - Street 1:15500 19 MILE RD
Mailing Address - Street 2:STE 310
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-6330
Mailing Address - Country:US
Mailing Address - Phone:586-263-6812
Mailing Address - Fax:
Practice Address - Street 1:15500 19 MILE RD
Practice Address - Street 2:STE 310
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48038-6330
Practice Address - Country:US
Practice Address - Phone:586-263-6812
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-20
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI103TA0700X, 103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & AgingGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMC012228OtherLIC
MI4769047Medicaid
MI4769056Medicaid
MIJT007751OtherLIC
MI0E02096OtherBCBSM
MI0E02096OtherBCBSM
MIMC012228OtherLIC