Provider Demographics
NPI:1699327429
Name:DETROIT MEDICAL CENTER
Entity type:Organization
Organization Name:DETROIT MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SREEDHAR REDDY
Authorized Official - Middle Name:
Authorized Official - Last Name:MITTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:865-771-5715
Mailing Address - Street 1:678 SELDEN ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2200
Mailing Address - Country:US
Mailing Address - Phone:865-771-5715
Mailing Address - Fax:
Practice Address - Street 1:3901 BEAUBIEN ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2119
Practice Address - Country:US
Practice Address - Phone:313-745-5147
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-11
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4351045516OtherMEDICAL LICENSE NUMBER