Healthcare Provider Details

I. General information

NPI: 1265421069
Provider Name (Legal Business Name): PEDIATRICS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

670 MALL DR
PORTAGE MI
49024-2878
US

IV. Provider business mailing address

670 MALL DR
PORTAGE MI
49024-2878
US

V. Phone/Fax

Practice location:
  • Phone: 269-327-1900
  • Fax: 269-327-1564
Mailing address:
  • Phone: 269-327-1900
  • Fax: 269-327-1564

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: STEPHEN R LULL
Title or Position: PRESIDENT
Credential: MD
Phone: 269-327-1900