Basic Information
| Provider Information | |||||||||
| NPI: | 1538107610 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SURESH | ||||||||
| FirstName: | SRINIVASAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1420 STEPHENSON HWY | ||||||||
| Address2: | SUITE 400-CREDENTIALING | ||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480831189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485815975 | ||||||||
| FaxNumber: | 2485815640 | ||||||||
| Practice Location | |||||||||
| Address1: | CHILDRENS HOSPITAL MI EMERGENCY MED | ||||||||
| Address2: | 3901 BEAUBIEN ER DEPT - MAIN BUILDING | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3137455260 | ||||||||
| FaxNumber: | 3139937166 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 06/20/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 4301061925 | MI | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0204X | 4301061925 | MI | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Emergency Medicine |
No ID Information.