Healthcare Provider Details

I. General information

NPI: 1487701298
Provider Name (Legal Business Name): PRADEEP G. PRABHU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 08/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HENRY FORD HEALTH SYSTEM 24565 HAIG ROAD
TAYLOR MI
48180
US

IV. Provider business mailing address

HENRY FORD HEALTH SYSTEM 24565 HAIG ROAD
TAYLOR MI
48180
US

V. Phone/Fax

Practice location:
  • Phone: 313-375-2000
  • Fax: 313-375-2165
Mailing address:
  • Phone: 313-375-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301062997
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: