Healthcare Provider Details

I. General information

NPI: 1952358327
Provider Name (Legal Business Name): SOUTH JACKSON PEDIATRICS, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2006
Last Update Date: 07/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

760 W FRANKLIN ST
JACKSON MI
49201-2048
US

IV. Provider business mailing address

760 W FRANKLIN ST
JACKSON MI
49201-2048
US

V. Phone/Fax

Practice location:
  • Phone: 517-780-9260
  • Fax: 517-780-9263
Mailing address:
  • Phone: 517-780-9260
  • Fax: 517-780-9263

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. SANDRA KILIAN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 517-780-9260