Basic Information
| Provider Information | |||||||||
| NPI: | 1740486349 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PABBATHI | ||||||||
| FirstName: | PRATHIMA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NALLABANTU | ||||||||
| OtherFirstName: | PRATHIMA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1540 LAKE LANSING RD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489123756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5179133900 | ||||||||
| FaxNumber: | 5179133901 | ||||||||
| Practice Location | |||||||||
| Address1: | 1540 LAKE LANSING RD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489123756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5179133900 | ||||||||
| FaxNumber: | 5179133901 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2007 | ||||||||
| LastUpdateDate: | 03/22/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4301089892 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200000025762 | 01 | MI | PHP- COMMERCIAL | OTHER | 0803304652 | 01 | MI | BLUE CROSS BLUE SHIELD OF MICHIGAN/BLUE CARE NETWORK | OTHER | P00893152 | 01 | MI | RAILROAD MEDICARE | OTHER | 1065666 | 01 | MI | MCLAREN HEALTH PLAN-MEDICAID | OTHER | 1065666 | 01 | MI | MCLAREN HEALTH PLAN-COMMERCIAL | OTHER | 9402523 | 01 | MI | AETNA | OTHER | 0M21440078 | 01 | MI | MEDICARE PLUS BLUE | OTHER | 1065666 | 01 | MI | MCLAREN HEALTH ADVANTAGE | OTHER | 200000025762 | 01 | MI | PHP- FAMILYCARE | OTHER |