Provider Demographics
NPI:1669493912
Name:POLICHERLA, HARANATH (MD)
Entity Type:Individual
Prefix:
First Name:HARANATH
Middle Name:
Last Name:POLICHERLA
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 1:20160 MACK AVENUE
Mailing Address - Street 2:ATTN: SRINIVAS.PULAPAKA
Mailing Address - City:GROSSE POINTE WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-1108
Mailing Address - Country:US
Mailing Address - Phone:313-882-0640
Mailing Address - Fax:313-882-3106
Practice Address - Street 1:26635 WOODWARD AVE
Practice Address - Street 2:STE. 101
Practice Address - City:HUNTINGTON WOODS
Practice Address - State:MI
Practice Address - Zip Code:48070-1372
Practice Address - Country:US
Practice Address - Phone:248-548-6400
Practice Address - Fax:248-548-8885
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010508062084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1308266221OtherBCBS PIN #
MI4377860Medicaid
A77168Medicare UPIN