Provider Demographics
NPI:1942325071
Name:CHACKO, REENU THANKAM
Entity Type:Individual
Prefix:
First Name:REENU
Middle Name:THANKAM
Last Name:CHACKO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:REENU
Other - Middle Name:THANKAM
Other - Last Name:SAMUEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1800 W BIG BEAVER RD
Mailing Address - Street 2:STE 150
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084
Mailing Address - Country:US
Mailing Address - Phone:248-649-2323
Mailing Address - Fax:248-649-5998
Practice Address - Street 1:14501 TELEGRAPH
Practice Address - Street 2:
Practice Address - City:REDFORD
Practice Address - State:MI
Practice Address - Zip Code:48239
Practice Address - Country:US
Practice Address - Phone:313-534-0300
Practice Address - Fax:313-534-6408
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRC013050208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation