Healthcare Provider Details

I. General information

NPI: 1265467682
Provider Name (Legal Business Name): VENKATESWARA RAO MALINENI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 03/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 NORTH AVE ST JOSEPH SPECIALTY HOSPITAL 215
MT CLEMENS MI
48045
US

IV. Provider business mailing address

5341 PROVINCIAL DR
BLOOMFIELD HILLS MI
48302
US

V. Phone/Fax

Practice location:
  • Phone: 586-466-9889
  • Fax: 586-466-9972
Mailing address:
  • Phone: 888-495-3999
  • Fax: 586-466-9972

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number283787-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: