Provider Demographics
NPI:1417001660
Name:SOUTHEAST MICHIGAN MEDICAL ASSOCIATES PC
Entity Type:Organization
Organization Name:SOUTHEAST MICHIGAN MEDICAL ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ASHOK
Authorized Official - Middle Name:KUMAR
Authorized Official - Last Name:BANSAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-827-7612
Mailing Address - Street 1:18451 W 12 MILE RD
Mailing Address - Street 2:STE 200
Mailing Address - City:LATHRUP VILLAGE
Mailing Address - State:MI
Mailing Address - Zip Code:48076-2644
Mailing Address - Country:US
Mailing Address - Phone:248-827-7612
Mailing Address - Fax:248-827-7615
Practice Address - Street 1:18451 W 12 MILE RD
Practice Address - Street 2:STE 200
Practice Address - City:LATHRUP VILLAGE
Practice Address - State:MI
Practice Address - Zip Code:48076-2644
Practice Address - Country:US
Practice Address - Phone:248-827-7612
Practice Address - Fax:248-827-7615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301057441207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1106306332OtherBCBSM
MI3150549Medicaid
MI1106306332OtherBCBSM
MIF63583Medicare UPIN
MI0N83280Medicare PIN