Healthcare Provider Details

I. General information

NPI: 1801001771
Provider Name (Legal Business Name): SERGIO BARTAKIAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2007
Last Update Date: 07/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CHILDREN'S HOSPITAL OF MI - 4TH 3901 BEAUBIEN
DETROIT MI
48201
US

IV. Provider business mailing address

UNIVERSITY PEDIATRICIANS 4201 ST. ANTOINE UHC 5D # 226
DETROIT MI
48201
US

V. Phone/Fax

Practice location:
  • Phone: 313-745-5481
  • Fax: 313-966-2423
Mailing address:
  • Phone: 313-966-5051
  • Fax: 313-966-0665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License NumberA121219
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number47596
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number57.011456
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301119342
License Number StateMI
# 5
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License NumberP7881
License Number StateTX
# 6
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number4301119342
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: