Provider Demographics
NPI:1518016955
Name:SUNDARAVARADAN, PARANTHAMAN (PT)
Entity Type:Individual
Prefix:
First Name:PARANTHAMAN
Middle Name:
Last Name:SUNDARAVARADAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33000 ANNAPOLIS ST STE 120
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:MI
Mailing Address - Zip Code:48184-2916
Mailing Address - Country:US
Mailing Address - Phone:734-721-8785
Mailing Address - Fax:734-721-2938
Practice Address - Street 1:33000 ANNAPOLIS ST STE 120
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:MI
Practice Address - Zip Code:48184-2916
Practice Address - Country:US
Practice Address - Phone:734-721-8785
Practice Address - Fax:734-721-2938
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2017-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501005636225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN20230006Medicare PIN