Provider Demographics
NPI:1619170644
Name:LATHA T KANNAN, MD, PC
Entity Type:Organization
Organization Name:LATHA T KANNAN, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LATHA
Authorized Official - Middle Name:T
Authorized Official - Last Name:KANNAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-353-4777
Mailing Address - Street 1:6715 BIRMINGHAM CLUB DRIVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48301
Mailing Address - Country:US
Mailing Address - Phone:248-353-4777
Mailing Address - Fax:248-353-4235
Practice Address - Street 1:6715 BIRMINGHAM CLUB DRIVE
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48301
Practice Address - Country:US
Practice Address - Phone:248-353-4777
Practice Address - Fax:248-353-4235
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-07
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MILK070401207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIH76165Medicare UPIN
MI0N88850Medicare PIN