Provider Demographics
NPI:1710912605
Name:BN NANDISH MD PC INC
Entity Type:Organization
Organization Name:BN NANDISH MD PC INC
Other - Org Name:B.N. NANDISH, MD PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:BANATHALLY
Authorized Official - Middle Name:NANJUNDASWAMY
Authorized Official - Last Name:NANDISH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-449-4032
Mailing Address - Street 1:PO BOX 247
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48376-0247
Mailing Address - Country:US
Mailing Address - Phone:248-449-4032
Mailing Address - Fax:248-449-4032
Practice Address - Street 1:45438 IRVINE DR
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48374-3772
Practice Address - Country:US
Practice Address - Phone:248-449-4032
Practice Address - Fax:248-449-4032
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301079475207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4858610Medicaid
MI0P31510Medicare PIN