Healthcare Provider Details

I. General information

NPI: 1851468441
Provider Name (Legal Business Name): RAJENDRA KANNEGANTI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 09/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20100 GREENFIELD RD
DETROIT MI
48235-1803
US

IV. Provider business mailing address

2115 BIRCHWOOD WAY
BLOOMFIELD HILLS MI
48302-1603
US

V. Phone/Fax

Practice location:
  • Phone: 313-342-2699
  • Fax: 313-342-2180
Mailing address:
  • Phone: 248-538-8992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number4301052433
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: