Healthcare Provider Details

I. General information

NPI: 1083792303
Provider Name (Legal Business Name): GAGANDEEP RANDHAWA, M.D., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 04/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5777 W MAPLE RD SUITE 180
WEST BLOOMFIELD MI
48322-2267
US

IV. Provider business mailing address

7225 CARLYLE XING
WEST BLOOMFIELD MI
48322-3280
US

V. Phone/Fax

Practice location:
  • Phone: 248-539-9084
  • Fax: 248-539-9088
Mailing address:
  • Phone: 248-539-9084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: AJITPAL RANDHAWA
Title or Position: SECRETARY
Credential:
Phone: 248-539-9084