Basic Information
| Provider Information | |||||||||
| NPI: | 1669493912 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | POLICHERLA | ||||||||
| FirstName: | HARANATH | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20160 MACK AVENUE | ||||||||
| Address2: | ATTN: SRINIVAS.PULAPAKA | ||||||||
| City: | GROSSE POINTE WOODS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482361108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138820640 | ||||||||
| FaxNumber: | 3138823106 | ||||||||
| Practice Location | |||||||||
| Address1: | 26635 WOODWARD AVE | ||||||||
| Address2: | STE. 101 | ||||||||
| City: | HUNTINGTON WOODS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480701372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485486400 | ||||||||
| FaxNumber: | 2485488885 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 4301050806 | MI | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 1308266221 | 01 | MI | BCBS PIN # | OTHER | 4377860 | 05 | MI | MEDICAID |