Basic Information
| Provider Information | |||||||||
| NPI: | 1053542498 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHEAST GUIDANCE CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20303 KELLY RD | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482251206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3132457000 | ||||||||
| FaxNumber: | 3132457009 | ||||||||
| Practice Location | |||||||||
| Address1: | 20303 KELLY RD | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482251206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3132457000 | ||||||||
| FaxNumber: | 3132457009 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2009 | ||||||||
| LastUpdateDate: | 08/03/2009 | ||||||||
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| AuthorizedOfficialLastName: | WEINGARDEN | ||||||||
| AuthorizedOfficialFirstName: | ADAM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | HOSPITAL LIAISON | ||||||||
| AuthorizedOfficialTelephone: | 3135509167 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 302R00000X | MI | Y | Managed Care Organizations | Health Maintenance Organization |
No ID Information.