Provider Demographics
NPI:1790970317
Name:SUBBANA G. MUTHUSWAMI, MD P.C.
Entity Type:Organization
Organization Name:SUBBANA G. MUTHUSWAMI, MD P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SUBBANA
Authorized Official - Middle Name:GOUNDER
Authorized Official - Last Name:MUTHUSWAMI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:810-987-5252
Mailing Address - Street 1:2603 ELECTRIC AVE
Mailing Address - Street 2:SUITE1
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-6588
Mailing Address - Country:US
Mailing Address - Phone:810-987-5252
Mailing Address - Fax:810-987-2120
Practice Address - Street 1:2603 ELECTRIC AVE
Practice Address - Street 2:SUITE1
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-6588
Practice Address - Country:US
Practice Address - Phone:810-987-5252
Practice Address - Fax:810-987-2120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-06
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301033903207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP25220Medicare UPIN