Provider Demographics
NPI:1760814289
Name:CENTER FOR INDIVIDUALIZED MEDICINE PLLC
Entity Type:Organization
Organization Name:CENTER FOR INDIVIDUALIZED MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SURJIT
Authorized Official - Middle Name:S
Authorized Official - Last Name:MAHAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:734-324-8000
Mailing Address - Street 1:PO BOX 251921
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48325-1921
Mailing Address - Country:US
Mailing Address - Phone:734-324-8000
Mailing Address - Fax:734-324-0993
Practice Address - Street 1:1404 BIDDLE AVE
Practice Address - Street 2:
Practice Address - City:WYANDOTTE
Practice Address - State:MI
Practice Address - Zip Code:48192-3706
Practice Address - Country:US
Practice Address - Phone:734-624-8000
Practice Address - Fax:734-326-1443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-07
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010464252084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Single Specialty