Healthcare Provider Details

I. General information

NPI: 1467639948
Provider Name (Legal Business Name): MALINI VENKATRAM MD .
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2008
Last Update Date: 11/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4160 JOHN R ST STE 917
DETROIT MI
48201-2020
US

IV. Provider business mailing address

1420 STEPHENSON HWY SUITE 400-CREDENTIALING
TROY MI
48083-1189
US

V. Phone/Fax

Practice location:
  • Phone: 313-745-4525
  • Fax: 313-745-0011
Mailing address:
  • Phone: 248-581-5972
  • Fax: 248-581-5640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301085459
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number4301085459
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: