MEDICARE: PEDIATRIC CARE CORNER PC

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	CR010295	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	350F375630	OTHER	MI	BCBC BCN

General Provider Information

NPI Number	:	1508864687
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRIC CARE CORNER PC

Provider Business Mailing Address
First Line	:	PO BOX 33321
Second Line	:	DRAWER 95
City	:	DETROIT
State	:	MI
Zip	:	48232-5321
Country	:	US
Telephone Number	:	248-926-1411
Fax Number	:	248-926-5338

Provider Business Practice Location Address
First Line	:	2300 HAGGERTY RD
Second Line	:	SUITE 2110
City	:	W BLOOMFIELD
State	:	MI
Zip	:	48323-2184
Country	:	US
Telephone Number	:	248-926-1411
Fax Number	:	248-926-5338

Authorized Official
Title or Position	:	OWNER/PHYSICIAN
Name	:	DR. CONSTANCE ROWLEY
Credential	:	DO
Telephone Number	:	248-926-1411

Provider Enumeration Date	:	07/12/2005
Last Update Date	:	10/16/2007

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