Provider Demographics
NPI:1124131479
Name:MADHAVAN, SANTHOSH (MD)
Entity type:Individual
Prefix:DR
First Name:SANTHOSH
Middle Name:
Last Name:MADHAVAN
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 1:30206 HICKORY LN
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:MI
Mailing Address - Zip Code:48025-2308
Mailing Address - Country:US
Mailing Address - Phone:248-761-9556
Mailing Address - Fax:
Practice Address - Street 1:26900 FRANKLIN RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48033-5312
Practice Address - Country:US
Practice Address - Phone:248-350-8070
Practice Address - Fax:248-350-8078
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301050998208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI25-0F34274-0OtherBCBS
2506334501OtherBCBS BCN
MI4149829Medicaid
MI0P40070Medicare PIN
MI4149829Medicaid