Provider Demographics
NPI:1467423194
Name:PAVANI KOLLI, MD PLC
Entity Type:Organization
Organization Name:PAVANI KOLLI, MD PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAVANI
Authorized Official - Middle Name:
Authorized Official - Last Name:KOLLI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:734-266-2780
Mailing Address - Street 1:24604 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-1742
Mailing Address - Country:US
Mailing Address - Phone:313-908-9374
Mailing Address - Fax:313-562-8511
Practice Address - Street 1:24604 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-1742
Practice Address - Country:US
Practice Address - Phone:313-908-9374
Practice Address - Fax:313-562-8511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-31
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N90730Medicare PIN