Provider Demographics
NPI:1225255367
Name:SUBBARAYAN, SHIVAKUMAR (RPT)
Entity Type:Individual
Prefix:
First Name:SHIVAKUMAR
Middle Name:
Last Name:SUBBARAYAN
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3076 NORTHRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:HALE
Mailing Address - State:MI
Mailing Address - Zip Code:48739-9277
Mailing Address - Country:US
Mailing Address - Phone:989-728-0242
Mailing Address - Fax:989-728-1144
Practice Address - Street 1:3076 NORTHRIDGE RD
Practice Address - Street 2:
Practice Address - City:HALE
Practice Address - State:MI
Practice Address - Zip Code:48739-9277
Practice Address - Country:US
Practice Address - Phone:989-728-0242
Practice Address - Fax:989-728-1144
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501008794174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4621772Medicaid
MI4621772Medicaid