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General NPI Number Information
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NPI Number | 1477809242
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Entity Type | Organization
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Legal Business Name | COOLMAC MEDICAL PC
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Dates
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Enumeration Date | 07/31/2012
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Last Update Date | 07/31/2012
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Provider Practice Location Address
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Address Line | 14825 W MCNICHOLS RD
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City | DETROIT
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State | MI
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Zip | 48235-3939
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Country | US
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Telephone | 313-838-7900
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Fax | 313-838-3476
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Provider Business Mailing Address
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Address Line | 28712 WINTERGREEN
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City | FARMINGTON HILLS
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State | MI
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Zip | 48331-3018
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Country | US
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Telephone | 313-838-7900
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Fax | 313-838-3476
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. PRAMOD RAVAL
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Credential | M.D.
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Telephone | 313-838-7900
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 4301043240
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License Number State | MI
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