Healthcare Provider Details

I. General information

NPI: 1962841544
Provider Name (Legal Business Name): SIRAJ PANCHBHAIYA D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2013
Last Update Date: 08/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11900 E 12 MILE RD STE 102
WARREN MI
48093-3487
US

IV. Provider business mailing address

20176 LIVERNOIS AVE 100
DETROIT MI
48221-1346
US

V. Phone/Fax

Practice location:
  • Phone: 586-573-7470
  • Fax: 586-573-0850
Mailing address:
  • Phone: 313-864-7385
  • Fax: 313-864-7384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number5901002488
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: