Provider Demographics
NPI:1609219690
Name:BERNADETTE ANGELES MD, PC
Entity Type:Organization
Organization Name:BERNADETTE ANGELES MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BERNADETTE
Authorized Official - Middle Name:LOURDES
Authorized Official - Last Name:ANGELES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-595-5215
Mailing Address - Street 1:21723 GARRISON ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2368
Mailing Address - Country:US
Mailing Address - Phone:313-595-5215
Mailing Address - Fax:
Practice Address - Street 1:42450 W 12 MILE RD
Practice Address - Street 2:SUITE 315
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377-3013
Practice Address - Country:US
Practice Address - Phone:248-513-4100
Practice Address - Fax:248-513-4105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-09
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010744662084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIF36490014Medicare UPIN