MEDICARE: MERIDIAN MEDICAL PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM1300X	Multi-Specialty Clinic/Center

General Provider Information

NPI Number	:	1447499694
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MERIDIAN MEDICAL PLLC

Provider Business Mailing Address
First Line	:	30781 STEPHENSON HWY
Second Line	:
City	:	MADISON HTS
State	:	MI
Zip	:	48071-1618
Country	:	US
Telephone Number	:	248-583-8922
Fax Number	:

Provider Business Practice Location Address
First Line	:	25650 OUTER DR
Second Line	:	SUITE 400
City	:	LINCOLN PARK
State	:	MI
Zip	:	48146-2096
Country	:	US
Telephone Number	:	313-383-9400
Fax Number	:	313-383-7163

Authorized Official
Title or Position	:	MANAGER
Name	:	RAM GUNABALAN
Credential	:	MD
Telephone Number	:	313-383-9400

Provider Enumeration Date	:	02/11/2009
Last Update Date	:	04/10/2009

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