Healthcare Provider Details

I. General information

NPI: 1821561127
Provider Name (Legal Business Name): PED PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2019
Last Update Date: 02/17/2023
Certification Date: 02/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 STEWART RD
MONROE MI
48162-4393
US

IV. Provider business mailing address

307 STEWART RD
MONROE MI
48162-4393
US

V. Phone/Fax

Practice location:
  • Phone: 734-243-5720
  • Fax:
Mailing address:
  • Phone: 734-243-5720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: VIJAYALAKSHMI RANGANATHA
Title or Position: MEMBER
Credential: MD
Phone: 330-207-8409