Basic Information
| Provider Information | |||||||||
| NPI: | 1568657146 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THAKUR | ||||||||
| FirstName: | NITI | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6200 PINE HOLLOW DR | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | EAST LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488239700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173391676 | ||||||||
| FaxNumber: | 5173392716 | ||||||||
| Practice Location | |||||||||
| Address1: | 6200 PINE HOLLOW DR | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | EAST LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488239700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173391676 | ||||||||
| FaxNumber: | 5173392716 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2007 | ||||||||
| LastUpdateDate: | 11/29/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RR0500X | 4301055581 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology |
ID Information
| ID | Type | State | Issuer | Description | 0331244 | 01 | MI | BLUE CARE NETWORK | OTHER | 1103312441 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER | 200000002343 | 01 | MI | PHP | OTHER | 10-5214000 | 05 | MI | MEDICAID |