MEDICARE: SHANVASECTOMY 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	207QA0505X	Adult Medicine Physician

General Provider Information

NPI Number	:	1750185849
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHANVASECTOMY PLLC

Provider Business Mailing Address
First Line	:	26711 WOODWARD AVE STE LLB
Second Line	:
City	:	HUNTINGTON WOODS
State	:	MI
Zip	:	48070-1370
Country	:	US
Telephone Number	:	313-314-6663
Fax Number	:

Provider Business Practice Location Address
First Line	:	26711 WOODWARD AVE STE LLB
Second Line	:
City	:	HUNTINGTON WOODS
State	:	MI
Zip	:	48070-1370
Country	:	US
Telephone Number	:	313-314-6663
Fax Number	:

Authorized Official
Title or Position	:	CEO/MD
Name	:	THULASI SHANMUKANATHAN
Credential	:	MD
Telephone Number	:	313-314-6663

Provider Enumeration Date	:	04/01/2025
Last Update Date	:	04/01/2025

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