Provider Demographics
NPI:1487867644
Name:SAMYUKTHA RANI MADISHETTY MD PC
Entity Type:Organization
Organization Name:SAMYUKTHA RANI MADISHETTY MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMYUKTHA
Authorized Official - Middle Name:RANI
Authorized Official - Last Name:MADISHETTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-561-3000
Mailing Address - Street 1:24100 OXFORD ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2481
Mailing Address - Country:US
Mailing Address - Phone:313-561-3000
Mailing Address - Fax:313-561-4831
Practice Address - Street 1:24100 OXFORD ST
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124
Practice Address - Country:US
Practice Address - Phone:313-561-3000
Practice Address - Fax:313-561-4831
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301080548207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI110H237950OtherBCBS GROUP
MI110H237950OtherBCN GROUP
MIDH0704OtherRAILROAD MEDICARE GROUP
MI1487867644Medicaid
MII46399OtherHAP
MI1487867644Medicaid