Provider Demographics
NPI:1679585343
Name:JAGADISH, MADHU C (PAC)
Entity Type:Individual
Prefix:
First Name:MADHU
Middle Name:C
Last Name:JAGADISH
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3893 GLEN FALLS DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48302-1226
Mailing Address - Country:US
Mailing Address - Phone:248-943-1644
Mailing Address - Fax:
Practice Address - Street 1:3893 GLEN FALLS DR
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302-1226
Practice Address - Country:US
Practice Address - Phone:248-943-1644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002987363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P16670018Medicare ID - Type Unspecified