Provider Demographics
NPI:1518133404
Name:TINA PICKETT BAISDEN MD PLLC
Entity Type:Organization
Organization Name:TINA PICKETT BAISDEN MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:TINA
Authorized Official - Middle Name:G
Authorized Official - Last Name:PICKETT BAISDEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-433-3803
Mailing Address - Street 1:PO BOX 250433
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:MI
Mailing Address - Zip Code:48025-0433
Mailing Address - Country:US
Mailing Address - Phone:248-433-3803
Mailing Address - Fax:
Practice Address - Street 1:31500 TELEGRAPH RD
Practice Address - Street 2:SUITE 130
Practice Address - City:BINGHAM FARMS
Practice Address - State:MI
Practice Address - Zip Code:48025-4367
Practice Address - Country:US
Practice Address - Phone:248-433-3803
Practice Address - Fax:248-433-3452
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-01
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MITP057574207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0706359621OtherBCBS MI
MI070015591OtherRAILROAD MEDICARE
MI0706359621OtherBCBS MI
MIG14051Medicare UPIN