Healthcare Provider Details

I. General information

NPI: 1740390848
Provider Name (Legal Business Name): SHYAM SUNDER MOUDGIL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 03/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25195 KELLY RD SUITE B
ROSEVILLE MI
48066-4909
US

IV. Provider business mailing address

25195 KELLY RD SUITE B
ROSEVILLE MI
48066-4909
US

V. Phone/Fax

Practice location:
  • Phone: 586-777-3370
  • Fax: 586-777-3380
Mailing address:
  • Phone: 586-777-3370
  • Fax: 586-777-3380

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301069080
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number4301069080
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: