Healthcare Provider Details

I. General information

NPI: 1467747873
Provider Name (Legal Business Name): PREETHA JANAKY IYENGAR MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2011
Last Update Date: 03/23/2023
Certification Date: 03/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

TRINITY HEALTH IHA MEDICAL GROUP PEDIATRIC-PLYMOUTH 900 W. ANN ARBOR TRAIL
PLYMOUTH MI
48170
US

IV. Provider business mailing address

24 FRANK LLOYD WRIGHT DRIVE SUITE J2000
ANN ARBOR MI
48105
US

V. Phone/Fax

Practice location:
  • Phone: 734-455-4600
  • Fax: 734-455-5637
Mailing address:
  • Phone: 734-747-6766
  • Fax: 734-222-3100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD042719
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301507967
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: