Healthcare Provider Details

I. General information

NPI: 1548960149
Provider Name (Legal Business Name): UNIVERSITY PEDIATRICIANS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2023
Last Update Date: 10/28/2024
Certification Date: 10/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 BEAUBIEN ST
DETROIT MI
48201-2119
US

IV. Provider business mailing address

3901 BEAUBIEN ST STE H
DETROIT MI
48201-2119
US

V. Phone/Fax

Practice location:
  • Phone: 313-745-5437
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: MARK HARRISON
Title or Position: COO
Credential:
Phone: 313-745-5870