MEDICARE: SUDHIR WALAVALKAR MD

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	207R00000X	Internal Medicine Physician	4301041018	MI
2	207RG0300X	Geriatric Medicine (Internal Medicine) Physician	SW041018	MI

General Provider Information

NPI Number	:	1730167552
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUDHIR WALAVALKAR MD

Provider Business Mailing Address
First Line	:	25925 TELEGRAPH RD
Second Line	:	210
City	:	SOUTHFIELD
State	:	MI
Zip	:	48033-2518
Country	:	US
Telephone Number	:	248-746-3218
Fax Number	:	248-746-0369

Provider Business Practice Location Address
First Line	:	22255 GREENFIELD RD
Second Line	:	310
City	:	SOUTHFIELD
State	:	MI
Zip	:	48075-3710
Country	:	US
Telephone Number	:	248-849-4990
Fax Number	:	248-849-4991

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

Provider Enumeration Date	:	01/03/2006
Last Update Date	:	12/29/2011

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