Provider Demographics
NPI:1407015795
Name:COMPREHENSIVE TREATMENT CENTER P.C.
Entity Type:Organization
Organization Name:COMPREHENSIVE TREATMENT CENTER P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KOTHEGALA
Authorized Official - Middle Name:PUTTANNIAH
Authorized Official - Last Name:JAGADISH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-333-9556
Mailing Address - Street 1:35 S JOHNSON ST
Mailing Address - Street 2:STE 2 H
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48341-1658
Mailing Address - Country:US
Mailing Address - Phone:248-333-9556
Mailing Address - Fax:248-333-9556
Practice Address - Street 1:35 S JOHNSON ST
Practice Address - Street 2:STE 2 H
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-1658
Practice Address - Country:US
Practice Address - Phone:248-333-9556
Practice Address - Fax:248-333-9556
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMPREHENSIVE TREATMENT CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-06-03
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301043330261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P61080OtherMEDICARE PTAN