Provider Demographics
NPI:1326194168
Name:MICHIGAN PSYCIATRIC & BEHAVIORAL ASSOCIATES PC
Entity Type:Organization
Organization Name:MICHIGAN PSYCIATRIC & BEHAVIORAL ASSOCIATES PC
Other - Org Name:MPBA
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KISHORE
Authorized Official - Middle Name:
Authorized Official - Last Name:KONDAPANENI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:989-922-4900
Mailing Address - Street 1:690 S TRUMBULL ST
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48708-7656
Mailing Address - Country:US
Mailing Address - Phone:989-922-4900
Mailing Address - Fax:989-922-4911
Practice Address - Street 1:690 S TRUMBULL ST
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48708-7656
Practice Address - Country:US
Practice Address - Phone:989-922-4900
Practice Address - Fax:989-922-4911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI260Z910350OtherBCBS
MION34080OtherMEDICARE
MION34080OtherMEDICARE