Healthcare Provider Details

I. General information

NPI: 1912577719
Provider Name (Legal Business Name): RAHUL PUTTAGUNTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2021
Last Update Date: 06/25/2021
Certification Date: 06/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16001 W 9 MILE RD
SOUTHFIELD MI
48075-4818
US

IV. Provider business mailing address

4853 GULLANE DR
ANN ARBOR MI
48103-8701
US

V. Phone/Fax

Practice location:
  • Phone: 248-849-3015
  • Fax:
Mailing address:
  • Phone: 989-600-0144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number4351048449
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: