Basic Information
| Provider Information | |||||||||
| NPI: | 1730417288 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AGE MANAGEMENT AND HORMONE BALANCE CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1787 GRAND RIDGE CT NE | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495257042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6168082695 | ||||||||
| FaxNumber: | 6168082697 | ||||||||
| Practice Location | |||||||||
| Address1: | 1787 GRAND RIDGE CT NE | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495257042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6168082695 | ||||||||
| FaxNumber: | 6168082697 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2009 | ||||||||
| LastUpdateDate: | 09/17/2012 | ||||||||
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| AuthorizedOfficialLastName: | BHATNAGAR | ||||||||
| AuthorizedOfficialFirstName: | PIYUSH | ||||||||
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| AuthorizedOfficialTitleorPosition: | INTERNIST-MANAGING DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6168082695 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301076867 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.