Provider Demographics
NPI:1619072055
Name:RUDRAIAH, LALITHA (MD)
Entity Type:Individual
Prefix:
First Name:LALITHA
Middle Name:
Last Name:RUDRAIAH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2689 SOLUTION CENTER
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-3848
Mailing Address - Country:US
Mailing Address - Phone:586-329-1880
Mailing Address - Fax:586-231-0055
Practice Address - Street 1:15500 19 MILE RD STE 360
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-6331
Practice Address - Country:US
Practice Address - Phone:586-649-9009
Practice Address - Fax:586-690-8632
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301076745207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5177416-10Medicaid
MI5177416-10Medicaid