Healthcare Provider Details

I. General information

NPI: 1285920462
Provider Name (Legal Business Name): MY SECOND HOME PEDIATRICS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2011
Last Update Date: 07/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31000 TELEGRAPH RD SUTIE 100
BINGHAM FARMS MI
48025-4360
US

IV. Provider business mailing address

31000 TELEGRAPH RD SUITE 100
BINGHAM FARMS MI
48025-4360
US

V. Phone/Fax

Practice location:
  • Phone: 248-865-0030
  • Fax:
Mailing address:
  • Phone: 248-865-0030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2732113
License Number StateMI

VIII. Authorized Official

Name: DR. KALPANA SHAH
Title or Position: MEMBER
Credential: M.D.
Phone: 248-865-0030