Healthcare Provider Details

I. General information

NPI: 1144238742
Provider Name (Legal Business Name): BANUMATHY SUBRAMANIAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 03/10/2021
Certification Date: 03/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29703 HOOVER RD STEB
WARREN MI
48093-8901
US

IV. Provider business mailing address

20225 E 9 MILE RD STE A
SAINT CLAIR SHORES MI
48080-1700
US

V. Phone/Fax

Practice location:
  • Phone: 586-573-9090
  • Fax: 586-573-2128
Mailing address:
  • Phone: 586-573-9090
  • Fax: 586-573-2128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301076114
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: