Healthcare Provider Details

I. General information

NPI: 1891258968
Provider Name (Legal Business Name): SHYAM KRISHNA POUDEL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2019
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 W 13 MILE RD
ROYAL OAK MI
48073-6712
US

IV. Provider business mailing address

3601 W 13 MILE RD
ROYAL OAK MI
48073-6712
US

V. Phone/Fax

Practice location:
  • Phone: 248-551-6347
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number036180469
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036180469
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: