Healthcare Provider Details

I. General information

NPI: 1104973916
Provider Name (Legal Business Name): KANTHI SANKAR RAJAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 03/18/2021
Certification Date: 03/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 KERCHEVAL AVE
GROSSE POINTE FARMS MI
48236-3629
US

IV. Provider business mailing address

131 KERCHEVAL AVE SUITE 10
GROSSE POINTE FARMS MI
48236-3629
US

V. Phone/Fax

Practice location:
  • Phone: 313-882-7900
  • Fax: 313-640-2253
Mailing address:
  • Phone: 313-882-7900
  • Fax: 313-640-2253

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301069868
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: