Healthcare Provider Details

I. General information

NPI: 1295875342
Provider Name (Legal Business Name): VINAYA VALLABHANENI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 07/08/2007
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: 313-916-9106
  • Fax: 313-916-1249
Mailing address:
  • Phone: 313-916-9106
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number4301065655
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: