Healthcare Provider Details

I. General information

NPI: 1518056340
Provider Name (Legal Business Name): PEDIATRIC PHYSICIANS OF LANSING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 01/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 E MICHIGAN AVE
LANSING MI
48912-1800
US

IV. Provider business mailing address

DEPT CH 17787
PALATINE IL
60055-0001
US

V. Phone/Fax

Practice location:
  • Phone: 517-364-5422
  • Fax: 517-364-5439
Mailing address:
  • Phone: 800-968-6866
  • Fax: 616-532-7230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MARK D ISREAL
Title or Position: PRESIDENT
Credential:
Phone: 517-371-4719