Healthcare Provider Details

I. General information

NPI: 1174691547
Provider Name (Legal Business Name): PEDIATRIC HOLISTIC MEDICINE, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2350 WASHTENAW AVE STE 24
ANN ARBOR MI
48104-4532
US

IV. Provider business mailing address

2350 WASHTENAW AVE STE 24
ANN ARBOR MI
48104-4532
US

V. Phone/Fax

Practice location:
  • Phone: 734-213-0255
  • Fax: 734-213-0241
Mailing address:
  • Phone: 734-213-0255
  • Fax: 734-213-0241

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. SUSAN MCCREADIE
Title or Position: OWNER
Credential: MD
Phone: 734-213-0255