Healthcare Provider Details

I. General information

NPI: 1669411310
Provider Name (Legal Business Name): PRAKASH SARVEPALLI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 09/28/2023
Certification Date: 09/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1021 E. MAIN STREET
EDMORE MI
48829-9737
US

IV. Provider business mailing address

1021 E. MAIN STREET
EDMORE MI
48829-9737
US

V. Phone/Fax

Practice location:
  • Phone: 989-427-5320
  • Fax: 989-427-8220
Mailing address:
  • Phone: 989-427-5320
  • Fax: 989-427-8220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301071121
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: