Healthcare Provider Details

I. General information

NPI: 1801362272
Provider Name (Legal Business Name): SOUNDARARAJAN DURAISAMY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2018
Last Update Date: 10/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 COOPER ST
JACKSON MI
49202-3398
US

IV. Provider business mailing address

1842 STEEPLECHASE RD
CANTON MI
48188-2565
US

V. Phone/Fax

Practice location:
  • Phone: 517-780-9500
  • Fax:
Mailing address:
  • Phone: 517-862-6648
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number5501014241
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: