Healthcare Provider Details

I. General information

NPI: 1962003566
Provider Name (Legal Business Name): BLUE WATER CHILDREN'S HEALTH CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2020
Last Update Date: 11/02/2020
Certification Date: 11/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3030 COMMERCE DR
FORT GRATIOT MI
48059-3819
US

IV. Provider business mailing address

3030 COMMERCE DR
FORT GRATIOT MI
48059-3819
US

V. Phone/Fax

Practice location:
  • Phone: 810-385-9559
  • Fax: 810-385-9515
Mailing address:
  • Phone: 810-385-9559
  • Fax: 810-385-9515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DEV NANDAMUDI
Title or Position: MD
Credential: MD
Phone: 810-385-9559