Individual
SANJAY G. REVANKAR
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
3901 CHRYSLER DR, SUITE 4A, DETROIT, MI 48201-2167
(313) 745-4525
(313) 577-3223
Mailing address
1560 E MAPLE RD, SUITE 400-CREDENTIALING, TROY, MI 48083-1189
(248) 581-5972
(248) 581-5640
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
4301057946
MI
207RI0200X
Infectious Disease Physician
Primary
4301057946
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
488412910
—
MI
01
—
700H262220
BLUE CROSS-BLUE CROSS
—
01
—
SR057946
CHAMPUS-CHAMPUS
—
Enumeration date
06/01/2006
Last updated
04/18/2016
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