Basic Information
| Provider Information | |||||||||
| NPI: | 1548278997 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRASAD SHANKARIAH MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1201 SOUTH DR | ||||||||
| Address2: | STE 131 | ||||||||
| City: | MT PLEASANT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488583256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897795250 | ||||||||
| FaxNumber: | 9897795251 | ||||||||
| Practice Location | |||||||||
| Address1: | 1201 SOUTH DR | ||||||||
| Address2: | STE 131 | ||||||||
| City: | MT PLEASANT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488583256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897795250 | ||||||||
| FaxNumber: | 9897795251 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 06/25/2010 | ||||||||
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| AuthorizedOfficialLastName: | KAVANAGH | ||||||||
| AuthorizedOfficialFirstName: | FLORENCE | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 9897795250 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301066496 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4381630 | 05 | MI | MEDICAID |