Basic Information
Provider Information | |||||||||
NPI: | 1962570416 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PATEL | ||||||||
FirstName: | VIPUL | ||||||||
MiddleName: | R. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 41941 CONNERWOOD CT | ||||||||
Address2: |   | ||||||||
City: | CANTON | ||||||||
State: | MI | ||||||||
PostalCode: | 481873592 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 6773 W MAPLE RD | ||||||||
Address2: |   | ||||||||
City: | WEST BLOOMFIELD | ||||||||
State: | MI | ||||||||
PostalCode: | 483223013 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2486616100 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/01/2006 | ||||||||
LastUpdateDate: | 09/01/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/01/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 066701 | MI | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RA0401X | 4301066701 | MI | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Addiction Medicine |
ID Information
ID | Type | State | Issuer | Description | 700H262220 | 01 |   | BLUE CROSS-BLUE CROSS | OTHER | VP066701 | 01 |   | CHAMPUS-CHAMPUS | OTHER | 322386010 | 05 | MI |   | MEDICAID | VP066701 | 01 |   | COMMERCIAL-COMMERCIAL NUMBER | OTHER |