Healthcare Provider Details

I. General information

NPI: 1306376173
Provider Name (Legal Business Name): VISHNU TEJA PEMMARAJU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2017
Last Update Date: 01/30/2026
Certification Date: 01/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3106 S WAYNE RD
WAYNE MI
48184-1221
US

IV. Provider business mailing address

3106 S WAYNE RD
WAYNE MI
48184-1221
US

V. Phone/Fax

Practice location:
  • Phone: 734-722-6300
  • Fax: 734-722-4815
Mailing address:
  • Phone: 734-722-6300
  • Fax: 734-722-4815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number4301510107
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number4301510107
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: