Provider Demographics
NPI:1871548453
Name:MAHADEVAN, SANGANUR V (MD)
Entity type:Individual
Prefix:
First Name:SANGANUR
Middle Name:V
Last Name:MAHADEVAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11477 E 12 MILE RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-2678
Mailing Address - Country:US
Mailing Address - Phone:586-751-0200
Mailing Address - Fax:586-751-0414
Practice Address - Street 1:11477 E 12 MILE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-2678
Practice Address - Country:US
Practice Address - Phone:586-751-0200
Practice Address - Fax:586-751-0414
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301033200208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI11-08067781OtherBCBSM
MI2095952Medicaid
MI11-08067781OtherBCBSM
MI0826778Medicare ID - Type Unspecified