Basic Information
| Provider Information | |||||||||
| NPI: | 1962841544 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PANCHBHAIYA | ||||||||
| FirstName: | SIRAJ | ||||||||
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| Credential: | D.P.M. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20176 LIVERNOIS AVE 100 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482211346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138647385 | ||||||||
| FaxNumber: | 3138647384 | ||||||||
| Practice Location | |||||||||
| Address1: | 11900 E 12 MILE RD STE 102 | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480933487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5865737470 | ||||||||
| FaxNumber: | 5865730850 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2013 | ||||||||
| LastUpdateDate: | 08/12/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 5901002488 | MI | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
No ID Information.