Provider Demographics
NPI: | 1518962133 |
---|---|
Name: | MULPURI, RAGHU (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | RAGHU |
Middle Name: | |
Last Name: | MULPURI |
Suffix: | |
Gender: | M |
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: | 625 PERRIEN PL |
Mailing Address - Street 2: | |
Mailing Address - City: | GROSSE POINTE WOODS |
Mailing Address - State: | MI |
Mailing Address - Zip Code: | 48236-1132 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 248-265-4080 |
Mailing Address - Fax: | 248-265-4082 |
Practice Address - Street 1: | 27450 SCHOENHERR RD |
Practice Address - Street 2: | SUITE 500 |
Practice Address - City: | WARREN |
Practice Address - State: | MI |
Practice Address - Zip Code: | 48088-6683 |
Practice Address - Country: | US |
Practice Address - Phone: | 586-582-7632 |
Practice Address - Fax: | 586-582-7633 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-06-20 |
Last Update Date: | 2017-03-15 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MI | 4301061786 | 207R00000X, 208M00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 208M00000X | Allopathic & Osteopathic Physicians | Hospitalist | |
No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
G76181 | Medicare UPIN | ||
MI | 0P29620 | Medicare ID - Type Unspecified | |
MI | 4841598 | Medicaid | |
G76181 | Medicare UPIN |