Provider Demographics
NPI:1568640746
Name:SURESH, KANDASAMY (RPT)
Entity Type:Individual
Prefix:MR
First Name:KANDASAMY
Middle Name:
Last Name:SURESH
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5521 HOUGHTEN DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48098-2908
Mailing Address - Country:US
Mailing Address - Phone:248-301-0001
Mailing Address - Fax:
Practice Address - Street 1:5521 HOUGHTEN DR
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48098-2908
Practice Address - Country:US
Practice Address - Phone:248-301-0001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-10
Last Update Date:2020-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501005288171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4539664Medicaid