Healthcare Provider Details

I. General information

NPI: 1598196677
Provider Name (Legal Business Name): UMAKANTH REDDY JAGU
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2013
Last Update Date: 11/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22950 NORTHINE ROAD
TAYLOR MI
48180
US

IV. Provider business mailing address

37845 DALE DR # 302
WESTLAND MI
48185-7526
US

V. Phone/Fax

Practice location:
  • Phone: 734-287-1230
  • Fax:
Mailing address:
  • Phone: 734-693-5780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501014042
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: