Healthcare Provider Details

I. General information

NPI: 1568640746
Provider Name (Legal Business Name): KANDASAMY SURESH RPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2008
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5521 HOUGHTEN DR
TROY MI
48098-2908
US

IV. Provider business mailing address

5521 HOUGHTEN DR
TROY MI
48098-2908
US

V. Phone/Fax

Practice location:
  • Phone: 248-301-0001
  • Fax:
Mailing address:
  • Phone: 734-578-6369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501005288
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: