Basic Information
| Provider Information | |||||||||
| NPI: | 1417969163 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BIOSERENITY DT INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 99 ROSEWOOD DR STE 245 | ||||||||
| Address2: | |||||||||
| City: | DANVERS | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019234537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9785367400 | ||||||||
| FaxNumber: | 9785359778 | ||||||||
| Practice Location | |||||||||
| Address1: | 32100 TELEGRAPH RD | ||||||||
| Address2: | SUITE 145 | ||||||||
| City: | BINGHAM FARMS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2482810151 | ||||||||
| FaxNumber: | 2482810156 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2006 | ||||||||
| LastUpdateDate: | 05/10/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SHOCK | ||||||||
| AuthorizedOfficialFirstName: | JANICE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EVP CLINICAL OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 2145323757 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QS1200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Sleep Disorder Diagnostic |
ID Information
| ID | Type | State | Issuer | Description | 0N69430 | 01 | MI | PREFERRED HEALTHPLAN | OTHER | 0N69430 | 01 | MI | HAP | OTHER | 004251 | 01 | MI | MIDWEST HEALTH PLAN | OTHER |