MEDICARE: BIRMINGHAM SKIN & HAIR AESTHETICS 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	363AM0700X	Medical Physician Assistant	4301067927	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1720524218
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BIRMINGHAM SKIN & HAIR AESTHETICS PLLC

Provider Business Mailing Address
First Line	:	751 CHESTNUT ST
Second Line	:	SUITE 102
City	:	BIRMINGHAM
State	:	MI
Zip	:	48009-6461
Country	:	US
Telephone Number	:	248-593-1000
Fax Number	:

Provider Business Practice Location Address
First Line	:	751 CHESTNUT ST
Second Line	:	SUITE 102
City	:	BIRMINGHAM
State	:	MI
Zip	:	48009-6461
Country	:	US
Telephone Number	:	248-593-1000
Fax Number	:

Authorized Official
Title or Position	:	OFFICIAL
Name	:	DR. VENKAT RUDRARAJU
Credential	:	MD
Telephone Number	:	248-593-1000

Provider Enumeration Date	:	01/09/2017
Last Update Date	:	01/09/2017

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