Healthcare Provider Details

I. General information

NPI: 1659523876
Provider Name (Legal Business Name): PEDIATRIC CENTER OF JACKSON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2008
Last Update Date: 10/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1418 E MICHIGAN AVE
JACKSON MI
49202-3518
US

IV. Provider business mailing address

1418 E MICHIGAN AVE
JACKSON MI
49202-3518
US

V. Phone/Fax

Practice location:
  • Phone: 517-783-1779
  • Fax: 517-783-1899
Mailing address:
  • Phone: 517-783-1779
  • Fax: 517-783-1899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberSS068721
License Number StateMI

VIII. Authorized Official

Name: DR. SOUHA S HAKIM
Title or Position: OWNER
Credential: M.D.
Phone: 517-783-1779