Healthcare Provider Details

I. General information

NPI: 1457295776
Provider Name (Legal Business Name): KIRAN SOORAJ THIRUKONDA JEGADEESH BABU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2026
Last Update Date: 04/16/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HENRY FORD MACOMB HOSPITAL 15855 19 MILE RD.,
CLINTON TOWNSHIP MI
48038
US

IV. Provider business mailing address

HENRY FORD MACOMB HOSPITAL 15855 19 MILE RD.,
CLINTON TOWNSHIP MI
48038
US

V. Phone/Fax

Practice location:
  • Phone: 313-916-1601
  • Fax: 313-916-2018
Mailing address:
  • Phone: 313-916-1601
  • Fax: 313-916-2018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: