Provider Demographics
NPI:1801061957
Name:PONNIAH MOHAN MD PC
Entity type:Organization
Organization Name:PONNIAH MOHAN MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:PONNIAH
Authorized Official - Middle Name:
Authorized Official - Last Name:MOHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-574-2020
Mailing Address - Street 1:11446 E 13 MILE RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-6571
Mailing Address - Country:US
Mailing Address - Phone:586-574-2020
Mailing Address - Fax:586-574-2919
Practice Address - Street 1:11446 E 13 MILE RD
Practice Address - Street 2:SUITE B
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-6571
Practice Address - Country:US
Practice Address - Phone:586-574-2020
Practice Address - Fax:586-574-2919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-29
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIPM039179208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3505021342OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MI1682676Medicaid