Provider Demographics
NPI:1669532537
Name:MENON, MANI (MD)
Entity type:Individual
Prefix:
First Name:MANI
Middle Name:
Last Name:MENON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HENRY FORD HEALTH SYSTEM
Mailing Address - Street 2:2799 WEST GRAND BLVD - K9
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202
Mailing Address - Country:US
Mailing Address - Phone:313-916-2066
Mailing Address - Fax:313-916-2086
Practice Address - Street 1:HENRY FORD HEALTH SYSTEM
Practice Address - Street 2:2799 WEST GRAND BLVD - K9
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202
Practice Address - Country:US
Practice Address - Phone:313-916-2066
Practice Address - Fax:313-916-2086
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI071161208800000X
NY23293101208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
3408257931OtherBLUE CROSS-BLUE CROSS
MM071161OtherCOMMERCIAL-COMMERCIAL NUMBER
MM071161OtherCHAMPUS-CHAMPUS
MI338423410Medicaid
3408257931OtherBLUE CROSS-BLUE CROSS
MI338423410Medicaid