Provider Demographics
NPI:1548278997
Name:PRASAD SHANKARIAH MD PC
Entity type:Organization
Organization Name:PRASAD SHANKARIAH MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:FLORENCE
Authorized Official - Middle Name:E
Authorized Official - Last Name:KAVANAGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-779-5250
Mailing Address - Street 1:1201 SOUTH DR
Mailing Address - Street 2:STE 131
Mailing Address - City:MT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-3256
Mailing Address - Country:US
Mailing Address - Phone:989-779-5250
Mailing Address - Fax:989-779-5251
Practice Address - Street 1:1201 SOUTH DR
Practice Address - Street 2:STE 131
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-3256
Practice Address - Country:US
Practice Address - Phone:989-779-5250
Practice Address - Fax:989-779-5251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2010-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301066496207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4381630Medicaid
0N44570Medicare ID - Type Unspecified
MI4381630Medicaid