Healthcare Provider Details

I. General information

NPI: 1962780767
Provider Name (Legal Business Name): VILLAGE PEDIATRICS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2011
Last Update Date: 07/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31815 SOUTHFIELD RD SUITE 14
BEVERLY HILLS MI
48025-5471
US

IV. Provider business mailing address

31815 SOUTHFIELD RD SUITE 14
BEVERLY HILLS MI
48025-5471
US

V. Phone/Fax

Practice location:
  • Phone: 248-644-5626
  • Fax: 248-644-5497
Mailing address:
  • Phone: 248-644-5626
  • Fax: 248-644-5497

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. HERBERT J ROTH
Title or Position: PRESIDENT
Credential: M.D
Phone: 248-644-5626