Individual
DR. SUDHAKAR G. EZHUTHACHAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
HENRY FORD HEALTH SYSTEM, 2799 WEST GRAND BOULEVARD, DETROIT, MI 48202
(313) 916-2436
Mailing address
HENRY FORD HEALTH SYSTEM, 2799 WEST GRAND BOULEVARD, DETROIT, MI 48202
(313) 916-3146
(313) 916-8425
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
4301045923
MI
2080N0001X
Neonatal-Perinatal Medicine Physician
Primary
4301045923
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
143010410
—
MI
01
—
700H262280
BLUE CROSS-BLUE CROSS
—
01
—
SE045923
CHAMPUS-CHAMPUS
—
Enumeration date
11/15/2006
Last updated
07/16/2012
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