Healthcare Provider Details

I. General information

NPI: 1033155692
Provider Name (Legal Business Name): CEREAL CITY PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 09/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2545 CAPITAL AVE SW
BATTLE CREEK MI
49015-7120
US

IV. Provider business mailing address

2545 CAPITAL AVE S.W.
BATTLE CREEK MI
49015
US

V. Phone/Fax

Practice location:
  • Phone: 269-969-8723
  • Fax: 269-969-8724
Mailing address:
  • Phone: 269-969-8723
  • Fax: 269-969-8724

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MRS. DIANE THOMAS
Title or Position: OFFICE MANAGER
Credential:
Phone: 269-969-8723