Healthcare Provider Details

I. General information

NPI: 1255378741
Provider Name (Legal Business Name): CHARLES BRIAN PELSHAW MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 01/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 BEAUBIEN 1ST FLOOR MAIN BUILDING CHILDRENS HOSPITAL MI
DETROIT MI
48201
US

IV. Provider business mailing address

4201 ST. ANTOINE - UHC 5D MAILBOX 226 UNIVERSITY PEDIATRICIANS
DETROIT MI
48201-2153
US

V. Phone/Fax

Practice location:
  • Phone: 313-993-2757
  • Fax:
Mailing address:
  • Phone: 313-745-4405
  • Fax: 313-966-0665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301063401
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2081P0010X
TaxonomyPediatric Rehabilitation Medicine Physician
License Number4301063401
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: