Healthcare Provider Details

I. General information

NPI: 1023197357
Provider Name (Legal Business Name): PEDIATRIC SPECIALISTS OF BLOOMFIELD HILLS,P.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43097 WOODWARD AVE SUITE 201
BLOOMFIELD HILLS MI
48302-5041
US

IV. Provider business mailing address

43097 WOODWARD AVE SUITE 201
BLOOMFIELD HILLS MI
48302-5041
US

V. Phone/Fax

Practice location:
  • Phone: 248-454-9000
  • Fax: 248-454-9100
Mailing address:
  • Phone: 248-454-9000
  • Fax: 248-454-9100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301067190
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301074881
License Number StateMI

VIII. Authorized Official

Name: DR. KIMBERLEE COLEMAN
Title or Position: PARTNER
Credential: M.D.
Phone: 248-454-9000