Healthcare Provider Details

I. General information

NPI: 1407068695
Provider Name (Legal Business Name): TRESTLEWOOD PEDIATRICS, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5082 LOVERS LANE
PORTAGE MI
49002
US

IV. Provider business mailing address

5082 LOVERS LANE
PORTAGE MI
49002
US

V. Phone/Fax

Practice location:
  • Phone: 269-381-0118
  • Fax: 269-381-4610
Mailing address:
  • Phone: 269-381-0118
  • Fax: 269-381-4610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberRP050795
License Number StateMI

VIII. Authorized Official

Name: DR. ROBERT PAGE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 269-381-0118