Basic Information
Provider Information | |||||||||
NPI: | 1053702506 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ISMAIL B. SENDI, MD PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | NEW OAKLAND CHILD-ADOLESCENT AND FAMILY CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6549 TOWN CENTER DR | ||||||||
Address2: |   | ||||||||
City: | CLARKSTON | ||||||||
State: | MI | ||||||||
PostalCode: | 483464824 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2486206400 | ||||||||
FaxNumber: | 2486206405 | ||||||||
Practice Location | |||||||||
Address1: | 8150 E 13 MILE RD | ||||||||
Address2: |   | ||||||||
City: | WARREN | ||||||||
State: | MI | ||||||||
PostalCode: | 480938700 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5868259700 | ||||||||
FaxNumber: | 5868259701 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/05/2015 | ||||||||
LastUpdateDate: | 02/05/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SENDI | ||||||||
AuthorizedOfficialFirstName: | KEVIN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE VP OF OPERATIONS | ||||||||
AuthorizedOfficialTelephone: | 2484679946 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | JD, MBA | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
ID | Type | State | Issuer | Description | 1074878 | 05 | MI |   | MEDICAID |