Healthcare Provider Details

I. General information

NPI: 1548913106
Provider Name (Legal Business Name): PUNEET SINGH SIDHU
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2022
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25130 SOUTHFIELD RD STE 105
SOUTHFIELD MI
48075-1900
US

IV. Provider business mailing address

25130 SOUTHFIELD RD STE 105
SOUTHFIELD MI
48075-1900
US

V. Phone/Fax

Practice location:
  • Phone: 248-234-6797
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number4704303228
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: