Provider Demographics
NPI:1386720324
Name:SUBBURAMAN SIVAKUMAR MD PC
Entity type:Organization
Organization Name:SUBBURAMAN SIVAKUMAR MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SUBBURAMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SIVAKUMAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:734-432-7070
Mailing Address - Street 1:37650 PROFESSIONAL CNT DR
Mailing Address - Street 2:STE 1010A
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154
Mailing Address - Country:US
Mailing Address - Phone:734-432-7070
Mailing Address - Fax:734-432-5170
Practice Address - Street 1:37650 PROFESSIONAL CNT DR
Practice Address - Street 2:STE 1010A
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154
Practice Address - Country:US
Practice Address - Phone:734-432-7070
Practice Address - Fax:734-432-5170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISS065284207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301165Medicaid
MI0N28260Medicare ID - Type Unspecified
MIG85533Medicare UPIN
0P37200Medicare PIN