Healthcare Provider Details

I. General information

NPI: 1083608806
Provider Name (Legal Business Name): ANURADHA PRABHU MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2005
Last Update Date: 04/28/2025
Certification Date: 04/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44199 DEQUINDRE RD STE 615 BEAUMONT PEDIATRIC SUBSPECIALTY CLINIC
TROY MI
48085-1128
US

IV. Provider business mailing address

26901 BEAUMONT BLVD STE 3D
SOUTHFIELD MI
48033-3849
US

V. Phone/Fax

Practice location:
  • Phone: 248-964-9660
  • Fax: 248-964-9665
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number4301056840
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: