Healthcare Provider Details

I. General information

NPI: 1477781169
Provider Name (Legal Business Name): PARKSIDE PEDIATRIC CLINIC,P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2009
Last Update Date: 07/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 4TH ST
JACKSON MI
49203-4518
US

IV. Provider business mailing address

2100 4TH ST
JACKSON MI
49203-4518
US

V. Phone/Fax

Practice location:
  • Phone: 517-787-4332
  • Fax: 517-787-4861
Mailing address:
  • Phone: 517-787-4332
  • Fax: 517-787-4861

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301 031905
License Number StateMI

VIII. Authorized Official

Name: KATIKINENI V RAO
Title or Position: PRESIDENT
Credential: MD
Phone: 517-787-4332