Provider Demographics
NPI:1912334756
Name:SUPRIYA, MRINAL (MD)
Entity type:Individual
Prefix:DR
First Name:MRINAL
Middle Name:
Last Name:SUPRIYA
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 1:6697 STILLWELL
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322
Mailing Address - Country:US
Mailing Address - Phone:313-577-0805
Mailing Address - Fax:
Practice Address - Street 1:6697 STILLWELL
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-1364
Practice Address - Country:US
Practice Address - Phone:248-882-5688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-10
Last Update Date:2013-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301104012282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital