Healthcare Provider Details

I. General information

NPI: 1811401045
Provider Name (Legal Business Name): SUPRA VASCULAR ASSOCIATES PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2017
Last Update Date: 01/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16507 SOUTHFIELD RD
ALLEN PARK MI
48101-2503
US

IV. Provider business mailing address

16507 SOUTHFIELD RD
ALLEN PARK MI
48101-2503
US

V. Phone/Fax

Practice location:
  • Phone: 313-389-0648
  • Fax: 313-389-3510
Mailing address:
  • Phone: 313-389-0648
  • Fax: 313-389-3510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: DR. SUDHEER UMMADI
Title or Position: MANAGER
Credential: MD
Phone: 313-389-0648