Provider Demographics
NPI:1720524218
Name:BIRMINGHAM SKIN & HAIR AESTHETICS PLLC
Entity Type:Organization
Organization Name:BIRMINGHAM SKIN & HAIR AESTHETICS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICIAL
Authorized Official - Prefix:DR
Authorized Official - First Name:VENKAT
Authorized Official - Middle Name:
Authorized Official - Last Name:RUDRARAJU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-593-1000
Mailing Address - Street 1:751 CHESTNUT ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-6461
Mailing Address - Country:US
Mailing Address - Phone:248-593-1000
Mailing Address - Fax:
Practice Address - Street 1:751 CHESTNUT ST
Practice Address - Street 2:SUITE 102
Practice Address - City:BIRMINGHAM
Practice Address - State:MI
Practice Address - Zip Code:48009-6461
Practice Address - Country:US
Practice Address - Phone:248-593-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-09
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4301067927363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4406149Medicaid
MIH2627Medicare UPIN