Healthcare Provider Details

I. General information

NPI: 1922140912
Provider Name (Legal Business Name): PEDIATRIC STAFF PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22341 W 8 MILE RD
DETROIT MI
48219-1217
US

IV. Provider business mailing address

22341 W 8 MILE RD
DETROIT MI
48219-1217
US

V. Phone/Fax

Practice location:
  • Phone: 313-255-2209
  • Fax: 313-255-0773
Mailing address:
  • Phone: 313-255-2209
  • Fax: 313-255-0773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number031683
License Number StateMI

VIII. Authorized Official

Name: DR. ANNE-MARE ICE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 313-255-2209