Healthcare Provider Details

I. General information

NPI: 1629120282
Provider Name (Legal Business Name): SANJEEV SHANMUGA VENKATARAMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 04/14/2023
Certification Date: 04/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W-4111 ANDOVER RD STE 100
BLOOMFIELD TOWNSHIP MI
48302-1911
US

IV. Provider business mailing address

4639 RAVINE DR
BLOOMFIELD HILLS MI
48301-3640
US

V. Phone/Fax

Practice location:
  • Phone: 248-290-5400
  • Fax: 248-290-5401
Mailing address:
  • Phone: 248-737-4525
  • Fax: 248-290-5401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberSV056477
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: