Healthcare Provider Details

I. General information

NPI: 1073010625
Provider Name (Legal Business Name): VERNOR PEDIATRIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2018
Last Update Date: 06/10/2021
Certification Date: 06/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4607 W VERNOR HWY
DETROIT MI
48209-2117
US

IV. Provider business mailing address

26206 W 12 MILE RD STE 106
SOUTHFIELD MI
48034-1799
US

V. Phone/Fax

Practice location:
  • Phone: 313-554-3300
  • Fax: 313-554-3303
Mailing address:
  • Phone: 248-354-1600
  • Fax: 248-354-1604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberNK069655
License Number StateMI

VIII. Authorized Official

Name: TERESA BALL
Title or Position: CPC
Credential:
Phone: 734-839-6610