Healthcare Provider Details

I. General information

NPI: 1558518613
Provider Name (Legal Business Name): SG PEDIATRICS OF LAKE ORION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2008
Last Update Date: 08/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1455 S LAPEER RD STE 134
LAKE ORION MI
48360-1468
US

IV. Provider business mailing address

1455 S LAPEER RD STE 134
LAKE ORION MI
48360-1468
US

V. Phone/Fax

Practice location:
  • Phone: 248-683-3385
  • Fax: 248-683-8441
Mailing address:
  • Phone: 248-683-3385
  • Fax: 248-683-8441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: SWARAJYALAXMI RAO
Title or Position: OWNER
Credential: MD
Phone: 248-638-3385