Healthcare Provider Details

I. General information

NPI: 1457391930
Provider Name (Legal Business Name): SHAILENDER VENKATRATNAM MADANI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 12/30/2022
Certification Date: 12/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

888 W BIG BEAVER RD STE 404
TROY MI
48084-4761
US

IV. Provider business mailing address

2040 SACHIN WAY
TROY MI
48084-3338
US

V. Phone/Fax

Practice location:
  • Phone: 248-717-2410
  • Fax: 248-717-2411
Mailing address:
  • Phone: 586-854-2305
  • Fax: 248-717-2411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301059836
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number4301059836
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: