MEDICARE: MRS. MANJULA ROY M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	4301035867	MI
2	208000000X	Pediatrics Physician	4301035867	MI

General Provider Information

NPI Number	:	1083842256
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MANJULA ROY M.D.

Provider Business Mailing Address
First Line	:	17950 WOODWARD AVE
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48203-2260
Country	:	US
Telephone Number	:	313-867-2300
Fax Number	:

Provider Business Practice Location Address
First Line	:	17950 WOODWARD AVE
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48203-2260
Country	:	US
Telephone Number	:	313-867-2300
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/26/2009
Last Update Date	:	06/26/2009

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