Provider Demographics
NPI:1215133673
Name:CHARLES G. GODOSHIAN, M.D., P.C.
Entity type:Organization
Organization Name:CHARLES G. GODOSHIAN, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:G
Authorized Official - Last Name:GODOSHIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-353-0882
Mailing Address - Street 1:27177 LAHSER RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-4714
Mailing Address - Country:US
Mailing Address - Phone:248-353-0882
Mailing Address - Fax:248-353-0883
Practice Address - Street 1:27177 LAHSER RD
Practice Address - Street 2:SUITE 104
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-4714
Practice Address - Country:US
Practice Address - Phone:248-353-0882
Practice Address - Fax:248-353-0883
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-22
Last Update Date:2009-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MICG046652207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1731411Medicaid
MI0F38121OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MIB44605Medicare UPIN
0P19960Medicare ID - Type Unspecified