Healthcare Provider Details

I. General information

NPI: 1669922977
Provider Name (Legal Business Name): SERENITY PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2016
Last Update Date: 11/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71 E LONG LAKE RD
BLOOMFIELD HILLS MI
48304-9996
US

IV. Provider business mailing address

71 E LONG LAKE RD
BLOOMFIELD HILLS MI
48304-9996
US

V. Phone/Fax

Practice location:
  • Phone: 248-533-0000
  • Fax: 248-785-3788
Mailing address:
  • Phone: 248-533-0000
  • Fax: 248-785-3788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DONNA M WILSON
Title or Position: OFFICE MANAGER
Credential:
Phone: 248-533-0000