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General NPI Number Information
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NPI Number | 1740794312
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Entity Type | Organization
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Legal Business Name | PRASAD MIKKILINENI MD
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Dates
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Enumeration Date | 11/19/2017
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Last Update Date | 11/19/2017
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Provider Practice Location Address
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Address Line | 36975 FIVE MILE RD
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City | LIVONIA
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State | MI
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Zip | 48154-1871
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Country | US
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Telephone | 734-464-0600
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Fax |
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Provider Business Mailing Address
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Address Line | 18576 SHADYSIDE ST
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City | LIVONIA
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State | MI
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Zip | 48152-3246
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Country | US
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Telephone | 734-674-2739
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Fax |
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Authorized Official
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Title or Position | BILLER
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Name | MS. IRENE LYNN MARTIN
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Credential |
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Telephone | 734-675-4273
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RG0300X
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Taxonomy Name | Geriatric Medicine (Internal Medicine) Physician
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License Number | 4301039936
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 4301039936
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License Number State | MI
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