Provider Demographics
NPI:1629153192
Name:SUBRAMANIAN, MUTHIAH (MD)
Entity Type:Individual
Prefix:
First Name:MUTHIAH
Middle Name:
Last Name:SUBRAMANIAN
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 1:2656 BYRD ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-4180
Mailing Address - Country:US
Mailing Address - Phone:313-271-4654
Mailing Address - Fax:313-271-3442
Practice Address - Street 1:4220 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:EAST CHINA
Practice Address - State:MI
Practice Address - Zip Code:48054-2200
Practice Address - Country:US
Practice Address - Phone:810-329-4736
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301061409207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1108200562OtherBLUE CROSS BLUE SHIELD
MI1108200562OtherBLUE CROSS BLUE SHIELD
MIG65016Medicare UPIN