Healthcare Provider Details

I. General information

NPI: 1124051990
Provider Name (Legal Business Name): SHELBY PEDIATRIC ASSOCIATES AND CHILD LUNG CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 03/27/2024
Certification Date: 03/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15125 22 MILE RD
SHELBY TOWNSHIP MI
48315-4406
US

IV. Provider business mailing address

15125 22 MILE RD
SHELBY TOWNSHIP MI
48315-4406
US

V. Phone/Fax

Practice location:
  • Phone: 586-532-0599
  • Fax: 586-566-8967
Mailing address:
  • Phone: 586-532-0599
  • Fax: 586-566-8967

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberAR2460549
License Number StateMI

VIII. Authorized Official

Name: MARIA PELLERITO
Title or Position: OFFICE MANAGER
Credential:
Phone: 586-532-0599