Healthcare Provider Details

I. General information

NPI: 1639443773
Provider Name (Legal Business Name): PREMIER VASCULAR CARE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2012
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 SOUTH BLVD E STE B75
ROCHESTER HILLS MI
48307-6122
US

IV. Provider business mailing address

3205 LEGACY CT
W BLOOMFIELD MI
48323-3634
US

V. Phone/Fax

Practice location:
  • Phone: 248-243-3935
  • Fax: 248-284-7530
Mailing address:
  • Phone: 583-573-8030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number4301093222
License Number StateMI

VIII. Authorized Official

Name: AJITH KADAKOL
Title or Position: PHYSICIAN / OWNER
Credential: MD
Phone: 586-573-8030