Provider Demographics
NPI:1639512817
Name:MAYURA MADANI M.D.P.L.L.C.
Entity Type:Organization
Organization Name:MAYURA MADANI M.D.P.L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MAYURA
Authorized Official - Middle Name:
Authorized Official - Last Name:MADANI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-833-4629
Mailing Address - Street 1:4727 ST ANTOINE
Mailing Address - Street 2:STE 402
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201
Mailing Address - Country:US
Mailing Address - Phone:313-833-4629
Mailing Address - Fax:313-833-4648
Practice Address - Street 1:4727 ST ANTOINE
Practice Address - Street 2:STE 402
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201
Practice Address - Country:US
Practice Address - Phone:313-833-4629
Practice Address - Fax:313-833-4648
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MAYURA MADANI M.D.P.L.L.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-04-08
Last Update Date:2013-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104788033Medicaid