Provider Demographics
NPI:1255528527
Name:PRAVEEN MODI, MD, PC
Entity type:Organization
Organization Name:PRAVEEN MODI, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PRAVEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MODI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-830-6697
Mailing Address - Street 1:43181 SANDSTONE DR
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48377-2718
Mailing Address - Country:US
Mailing Address - Phone:248-830-6697
Mailing Address - Fax:248-676-0814
Practice Address - Street 1:3200 PINE LAKE RD
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48324-1951
Practice Address - Country:US
Practice Address - Phone:248-830-6697
Practice Address - Fax:248-676-0814
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-01
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4620532Medicaid
MIH22174Medicare UPIN
MI4620532Medicaid