Provider Demographics
NPI:1457409971
Name:SHIVANA N. PRAKASH MDPC
Entity Type:Organization
Organization Name:SHIVANA N. PRAKASH MDPC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL SURGEON
Authorized Official - Prefix:
Authorized Official - First Name:SHIVANA
Authorized Official - Middle Name:N
Authorized Official - Last Name:PRAKASH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-263-8555
Mailing Address - Street 1:43311 COMMONS DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1109
Mailing Address - Country:US
Mailing Address - Phone:586-263-8555
Mailing Address - Fax:586-263-8558
Practice Address - Street 1:43311 COMMONS DR
Practice Address - Street 2:
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48038-1109
Practice Address - Country:US
Practice Address - Phone:586-263-8555
Practice Address - Fax:586-263-8558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISP407447208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3180584Medicaid
MI3180584Medicaid
MIE40005Medicare UPIN