Healthcare Provider Details

I. General information

NPI: 1386033272
Provider Name (Legal Business Name): MADANA JEEVANANDAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/14/2015
Last Update Date: 02/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 SAINT ANTOINE ST
DETROIT MI
48201-2153
US

IV. Provider business mailing address

4201 SAINT ANTOINE ST
DETROIT MI
48201-2153
US

V. Phone/Fax

Practice location:
  • Phone: 514-515-8052
  • Fax:
Mailing address:
  • Phone: 514-515-8052
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number4301-106057
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: