Provider Demographics
NPI:1467639948
Name:VENKATRAM, MALINI (MD )
Entity Type:Individual
Prefix:
First Name:MALINI
Middle Name:
Last Name:VENKATRAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1420 STEPHENSON HWY
Mailing Address - Street 2:SUITE 400-CREDENTIALING
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1189
Mailing Address - Country:US
Mailing Address - Phone:248-581-5972
Mailing Address - Fax:248-581-5640
Practice Address - Street 1:4160 JOHN R ST
Practice Address - Street 2:STE 917
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2020
Practice Address - Country:US
Practice Address - Phone:313-745-4525
Practice Address - Fax:313-745-0011
Is Sole Proprietor?:No
Enumeration Date:2008-01-27
Last Update Date:2013-11-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301085459207R00000X, 207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1346398971OtherGRP NPI
MI11-0F3636-0OtherBCBSM GRP PIN
MI205485614OtherTAX ID
MI5357970Medicaid
MI0P41360014Medicare PIN
MI0P30630779Medicare PIN