Provider Demographics
NPI:1518552413
Name:ANNAMMA PULLUKAT
Entity Type:Organization
Organization Name:ANNAMMA PULLUKAT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:ROY
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:PULLUKAT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-253-9600
Mailing Address - Street 1:44200 WOODWARD AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48341-5046
Mailing Address - Country:US
Mailing Address - Phone:248-253-9600
Mailing Address - Fax:248-253-0980
Practice Address - Street 1:44200 WOODWARD AVE STE 103
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-5046
Practice Address - Country:US
Practice Address - Phone:248-253-9600
Practice Address - Fax:248-253-0980
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ANNAMMA PULLUKAT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-03-03
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1932694767Medicaid