Healthcare Provider Details

I. General information

NPI: 1104358043
Provider Name (Legal Business Name): MANOJ KUMAR MBBS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2017
Last Update Date: 07/04/2020
Certification Date: 07/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 PARK AVE HENNEPIN COUNTY MEDICAL CENTER INTERNAL MEDICINE
MINNEAPOLIS MN
55415-1623
US

IV. Provider business mailing address

22301 FOSTER WINTER DR
SOUTHFIELD MI
48075-3707
IN

V. Phone/Fax

Practice location:
  • Phone: 612-873-6963
  • Fax: 612-904-4261
Mailing address:
  • Phone: 248-849-3541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number4351047193
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: