Provider Demographics
NPI:1558359596
Name:MACHA, MAHENDER (MD)
Entity Type:Individual
Prefix:
First Name:MAHENDER
Middle Name:
Last Name:MACHA
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:PO BOX 67000
Mailing Address - Street 2:DEPARTMENT 272801
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48267-0002
Mailing Address - Country:US
Mailing Address - Phone:517-817-7605
Mailing Address - Fax:517-817-7606
Practice Address - Street 1:1100 E MICHIGAN AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1847
Practice Address - Country:US
Practice Address - Phone:517-817-7605
Practice Address - Fax:517-817-7606
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-13
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD050898L208G00000X
MI4301064881208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015061690004Medicaid
G17260Medicare UPIN
612538EB2Medicare ID - Type Unspecified