Healthcare Provider Details

I. General information

NPI: 1295221034
Provider Name (Legal Business Name): SANDEEP KUMAR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2018
Last Update Date: 09/28/2025
Certification Date: 09/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2799 W GRAND BLVD
DETROIT MI
48202-2608
US

IV. Provider business mailing address

1 FORD PL STE 3A
DETROIT MI
48202-3450
US

V. Phone/Fax

Practice location:
  • Phone: 313-916-2600
  • Fax: 313-876-1305
Mailing address:
  • Phone: 313-874-4805
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number4301114665
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License NumberP115195
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number4301504713
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: