MEDICARE: VR JASTY MD PLC

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	2084P0805X	Geriatric Psychiatry Physician	4301057306	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1780746602
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VR JASTY MD PLC

Provider Business Mailing Address
First Line	:	6720 BIRMINGHAM CLUB DR
Second Line	:
City	:	BLOOMFIELD HILLS
State	:	MI
Zip	:	48301-3119
Country	:	US
Telephone Number	:	586-484-7159
Fax Number	:	248-385-5771

Provider Business Practice Location Address
First Line	:	1525 UNIVERSITY DR
Second Line	:
City	:	AUBURN HILLS
State	:	MI
Zip	:	48326-2675
Country	:	US
Telephone Number	:	586-484-7159
Fax Number	:	248-385-5771

Authorized Official
Title or Position	:	PSYCHIATRIST
Name	:	DR. VENKATA RAMANA JASTY
Credential	:	MD
Telephone Number	:	586-484-7159

Provider Enumeration Date	:	12/15/2006
Last Update Date	:	12/30/2024

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