Provider Demographics
NPI:1477809242
Name:COOLMAC MEDICAL PC
Entity Type:Organization
Organization Name:COOLMAC MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PRAMOD
Authorized Official - Middle Name:
Authorized Official - Last Name:RAVAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-838-7900
Mailing Address - Street 1:28712 WINTERGREEN
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48331-3018
Mailing Address - Country:US
Mailing Address - Phone:313-838-7900
Mailing Address - Fax:313-838-3476
Practice Address - Street 1:14825 W MCNICHOLS RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-3939
Practice Address - Country:US
Practice Address - Phone:313-838-7900
Practice Address - Fax:313-838-3476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-31
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301043240174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301043240OtherPHYSICIAN LICENSE
MI0631385OtherPTAN
MI0631385OtherPTAN