Healthcare Provider Details

I. General information

NPI: 1124131479
Provider Name (Legal Business Name): SANTHOSH MADHAVAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 09/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26900 FRANKLIN RD
SOUTHFIELD MI
48033-5312
US

IV. Provider business mailing address

30206 HICKORY LN
FRANKLIN MI
48025-2308
US

V. Phone/Fax

Practice location:
  • Phone: 248-350-8070
  • Fax: 248-350-8078
Mailing address:
  • Phone: 248-761-9556
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number4301050998
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: