Healthcare Provider Details

I. General information

NPI: 1346454295
Provider Name (Legal Business Name): MADHU PARAMESWAR MENON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 11/29/2021
Certification Date: 11/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2799 W GRAND BLVD PATHOLOGY K-6
DETROIT MI
48202-2608
US

IV. Provider business mailing address

43133 COVESIDE CIR APT. 1713
NOVI MI
48375-3273
US

V. Phone/Fax

Practice location:
  • Phone: 313-916-2042
  • Fax:
Mailing address:
  • Phone: 207-344-8555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZH0000X
TaxonomyHematology (Pathology) Physician
License Number4301103351
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207ZI0100X
TaxonomyImmunopathology Physician
License Number4301103351
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number4301103351
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code207ZH0000X
TaxonomyHematology (Pathology) Physician
License Number12066641-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: