1972675676 NPI number — DR. SUDHAKAR G. EZHUTHACHAN M.D.

Table of content: CYNTHIA C ROTHERMEL (NPI 1255586384)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972675676 NPI number — DR. SUDHAKAR G. EZHUTHACHAN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EZHUTHACHAN
Provider First Name:
SUDHAKAR
Provider Middle Name:
G.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1972675676
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/16/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
HENRY FORD HEALTH SYSTEM
Provider Second Line Business Mailing Address:
2799 WEST GRAND BOULEVARD
Provider Business Mailing Address City Name:
DETROIT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48202
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-916-3146
Provider Business Mailing Address Fax Number:
313-916-8425

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
HENRY FORD HEALTH SYSTEM
Provider Second Line Business Practice Location Address:
2799 WEST GRAND BOULEVARD
Provider Business Practice Location Address City Name:
DETROIT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48202
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-916-2436
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/15/2006

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: 208000000X , with the licence number:  4301045923 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080N0001X , with the licence number: 4301045923 , 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: 143010410 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: SE045923 . This is a "CHAMPUS-CHAMPUS" identifier . This identifiers is of the category "OTHER".
  • Identifier: SE045923 . This is a "COMMERCIAL-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 700H262280 . This is a "BLUE CROSS-BLUE CROSS" identifier . This identifiers is of the category "OTHER".




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