MEDICARE: COLLEEN LAROSE MIELE MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2080A0000X	Pediatric Adolescent Medicine Physician	4301061288	MI
2	208000000X	Pediatrics Physician	4301061288	MI
3	2080P0006X	Developmental - Behavioral Pediatrics Physician	4301061288	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1265431696
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COLLEEN LAROSE MIELE MD

Provider Business Mailing Address
First Line	:	1 FORD PL STE 3A
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48202-3450
Country	:	US
Telephone Number	:	313-874-4806
Fax Number	:

Provider Business Practice Location Address
First Line	:	3031 W GRAND BLVD
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48202-3046
Country	:	US
Telephone Number	:	313-916-3121
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/19/2005
Last Update Date	:	11/03/2025

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