Healthcare Provider Details

I. General information

NPI: 1346238920
Provider Name (Legal Business Name): PREECHA SUPANWANID, MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2005
Last Update Date: 03/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

921 ABBOTT RD
EAST LANSING MI
48823-3170
US

IV. Provider business mailing address

921 ABBOTT RD
EAST LANSING MI
48823-3170
US

V. Phone/Fax

Practice location:
  • Phone: 517-336-6950
  • Fax: 517-336-6952
Mailing address:
  • Phone: 517-336-6950
  • Fax: 517-336-6952

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number4301037471
License Number StateMI

VIII. Authorized Official

Name: DR. PREECHA SUPANWANID
Title or Position: PRESIDENT
Credential: MD
Phone: 517-336-6950