Provider Demographics
NPI:1346224250
Name:PURI, PRAVIN P (MD)
Entity type:Individual
Prefix:MR
First Name:PRAVIN
Middle Name:P
Last Name:PURI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1080 KIRTS BLVD
Mailing Address - Street 2:SUITE 700
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-4881
Mailing Address - Country:US
Mailing Address - Phone:248-362-2300
Mailing Address - Fax:248-362-5272
Practice Address - Street 1:1080 KIRTS BLVD
Practice Address - Street 2:SUITE 700
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-4881
Practice Address - Country:US
Practice Address - Phone:248-362-2300
Practice Address - Fax:248-362-5272
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2011-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010599662086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4219899Medicaid
G90386Medicare UPIN
0N06800Medicare ID - Type Unspecified