Provider Demographics
NPI:1437482981
Name:SUDHA NANNAPANENI MD PLLC
Entity Type:Organization
Organization Name:SUDHA NANNAPANENI MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUDHA
Authorized Official - Middle Name:
Authorized Official - Last Name:NANNAPANENI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-300-4083
Mailing Address - Street 1:18285 E 10 MILE RD STE 120
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-5806
Mailing Address - Country:US
Mailing Address - Phone:586-771-4830
Mailing Address - Fax:
Practice Address - Street 1:18285 E 10 MILE RD STE 120
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-5806
Practice Address - Country:US
Practice Address - Phone:586-771-4830
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-16
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301070308207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104290526Medicaid
MI0N13360Medicare PIN