Healthcare Provider Details

I. General information

NPI: 1720562937
Provider Name (Legal Business Name): HURON VALLEY HOUSE PEDS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2018
Last Update Date: 09/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 WILLIAM CARLS DR
COMMERCE TOWNSHIP MI
48382-2201
US

IV. Provider business mailing address

32406 FRANKLIN RD UNIT 250577
FRANKLIN MI
48025-7022
US

V. Phone/Fax

Practice location:
  • Phone: 248-937-5041
  • Fax:
Mailing address:
  • Phone: 248-760-0899
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. BASHAR SHABB QALIEH
Title or Position: DIRECTOR
Credential: MD
Phone: 810-220-3700