1770650889 NPI number — DR. SAMYUKTHA R MADISHETTY I M.D.

Table of content: DR. SAMYUKTHA R MADISHETTY I M.D. (NPI 1770650889)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770650889 NPI number — DR. SAMYUKTHA R MADISHETTY I M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MADISHETTY
Provider First Name:
SAMYUKTHA
Provider Middle Name:
R
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
I
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770650889
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/11/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24100 OXFORD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DEARBORN
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48124-2481
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-397-3928
Provider Business Mailing Address Fax Number:
313-278-5846

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
24100 OXFORD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DEARBORN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48124
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-561-3000
Provider Business Practice Location Address Fax Number:
313-561-4831
Provider Enumeration Date:
11/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  4301080548 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1108281851 . This is a "BCN IND" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1108281851 . This is a "BCBS IND" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: P00470436 . This is a "RAILROAD MEDICARE IND PIN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: I46399 . This is a "HAP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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