Healthcare Provider Details

I. General information

NPI: 1306814561
Provider Name (Legal Business Name): KONDRAGANTI P RAO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 11/02/2023
Certification Date: 11/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28111 HOOVER
WARREN MI
48093
US

IV. Provider business mailing address

50 N DEEPLANDS ROAD
GROSSE POINTE SHORES MI
48236
US

V. Phone/Fax

Practice location:
  • Phone: 586-573-0589
  • Fax: 586-573-3861
Mailing address:
  • Phone: 586-573-0589
  • Fax: 586-573-3861

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number4301032931
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number4301032931
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: