Provider Demographics
NPI:1164435145
Name:SHANMUGAVELU, SURESH K (PT, DPT)
Entity Type:Individual
Prefix:
First Name:SURESH
Middle Name:K
Last Name:SHANMUGAVELU
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24014 W RENWICK RD STE F
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60544-8708
Mailing Address - Country:US
Mailing Address - Phone:800-974-4378
Mailing Address - Fax:630-515-1536
Practice Address - Street 1:29950 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1355
Practice Address - Country:US
Practice Address - Phone:800-974-4378
Practice Address - Fax:630-515-1536
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501007122225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
N9991002Medicare PIN