Healthcare Provider Details

I. General information

NPI: 1972675676
Provider Name (Legal Business Name): SUDHAKAR G. EZHUTHACHAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 07/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HENRY FORD HEALTH SYSTEM 2799 WEST GRAND BOULEVARD
DETROIT MI
48202
US

IV. Provider business mailing address

HENRY FORD HEALTH SYSTEM 2799 WEST GRAND BOULEVARD
DETROIT MI
48202
US

V. Phone/Fax

Practice location:
  • Phone: 313-916-2436
  • Fax:
Mailing address:
  • Phone: 313-916-3146
  • Fax: 313-916-8425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301045923
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number4301045923
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: