Basic Information
| Provider Information | |||||||||
| NPI: | 1417230889 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | METRO DETROIT RENAL DOCTOR PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3272 | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486053272 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897971400 | ||||||||
| FaxNumber: | 9897974077 | ||||||||
| Practice Location | |||||||||
| Address1: | 1349 S ROCHESTER RD STE 115 | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483073151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2487594852 | ||||||||
| FaxNumber: | 2487594854 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2011 | ||||||||
| LastUpdateDate: | 04/29/2022 | ||||||||
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| AuthorizedOfficialLastName: | LATTUPALLI | ||||||||
| AuthorizedOfficialFirstName: | RAKESH | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3132476037 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 04/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
No ID Information.