Healthcare Provider Details

I. General information

NPI: 1558529628
Provider Name (Legal Business Name): PEDIATRIC CLINIC ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2008
Last Update Date: 11/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9365 N HAGGERTY RD
PLYMOUTH MI
48170-4622
US

IV. Provider business mailing address

9365 N HAGGERTY RD
PLYMOUTH MI
48170-4622
US

V. Phone/Fax

Practice location:
  • Phone: 734-459-9260
  • Fax: 734-459-0612
Mailing address:
  • Phone: 734-459-9260
  • Fax: 734-459-0612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MARY ALONZI
Title or Position: DOCTOR
Credential: DO
Phone: 734-459-9260