Healthcare Provider Details

I. General information

NPI: 1013223239
Provider Name (Legal Business Name): SAMBA SIVA REDDY BATHULA M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2010
Last Update Date: 05/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4160 JOHN R ST STE 1007 DMC ENT-HARPER PROFESSIONAL BUILDING
DETROIT MI
48201-2017
US

IV. Provider business mailing address

4160 JOHN R ST STE 1007 DMC ENT-HARPER PROFESSIONAL BUILDING
DETROIT MI
48201-2017
US

V. Phone/Fax

Practice location:
  • Phone: 313-966-9471
  • Fax: 313-966-9470
Mailing address:
  • Phone: 313-966-9471
  • Fax: 313-966-9470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License Number4301096231
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number4301096231
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: