Provider Demographics
NPI:1326249103
Name:JEGADEESH, SUDHAKARAN (PT, MBA)
Entity Type:Individual
Prefix:
First Name:SUDHAKARAN
Middle Name:
Last Name:JEGADEESH
Suffix:
Gender:M
Credentials:PT, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17418 W 10 MILE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-2951
Mailing Address - Country:US
Mailing Address - Phone:248-552-1012
Mailing Address - Fax:
Practice Address - Street 1:17418 W 10 MILE RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-2951
Practice Address - Country:US
Practice Address - Phone:248-552-1012
Practice Address - Fax:248-552-0657
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-30
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501007156225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N67460Medicare UPIN