Basic Information
| Provider Information | |||||||||
| NPI: | 1588614507 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POTHACAMURY | ||||||||
| FirstName: | SITAMAHALAKHMI | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | POTHACAMURY | ||||||||
| OtherFirstName: | LAKSHMI | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 812 E JOLLY RD | ||||||||
| Address2: | STE 210 | ||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489106818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173468410 | ||||||||
| FaxNumber: | 5173468291 | ||||||||
| Practice Location | |||||||||
| Address1: | 606 W SHIAWASSEE ST | ||||||||
| Address2: | |||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489331032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5174846482 | ||||||||
| FaxNumber: | 5173468291 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 09/02/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 4301045783 | MI | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 104688691 | 05 | MI | MEDICAID |