Healthcare Provider Details

I. General information

NPI: 1417121252
Provider Name (Legal Business Name): DETROIT RIVERVIEW PEDIATRICS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2008
Last Update Date: 11/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10201 E JEFFERSON AVE
DETROIT MI
48214-3149
US

IV. Provider business mailing address

DEPT 999360 PO BOX 33738
DETROIT MI
48232-3738
US

V. Phone/Fax

Practice location:
  • Phone: 313-821-3777
  • Fax: 313-824-3777
Mailing address:
  • Phone: 810-720-5715
  • Fax: 810-732-0891

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: GERARD MOSBY
Title or Position: OWNER
Credential:
Phone: 313-821-3777