Healthcare Provider Details

I. General information

NPI: 1871548453
Provider Name (Legal Business Name): SANGANUR V. MAHADEVAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11477 E 12 MILE RD
WARREN MI
48093-2678
US

IV. Provider business mailing address

11477 E 12 MILE RD
WARREN MI
48093-2678
US

V. Phone/Fax

Practice location:
  • Phone: 586-751-0200
  • Fax: 586-751-0414
Mailing address:
  • Phone: 586-751-0200
  • Fax: 586-751-0414

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number4301033200
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: