Healthcare Provider Details

I. General information

NPI: 1770680381
Provider Name (Legal Business Name): ELANGO EDHAYAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2006
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24025 GREATER MACK AVE STE 103
SAINT CLAIR SHORES MI
48080-4311
US

IV. Provider business mailing address

24025 GREATER MACK AVE STE 103
SAINT CLAIR SHORES MI
48080-4311
US

V. Phone/Fax

Practice location:
  • Phone: 586-806-3220
  • Fax: 586-350-0099
Mailing address:
  • Phone: 586-806-3220
  • Fax: 586-350-0099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number4301057065
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: