Healthcare Provider Details

I. General information

NPI: 1801453287
Provider Name (Legal Business Name): PEDIATRIC CARDIOLOGY OF SOUTHEASTREN MICHIGAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2019
Last Update Date: 05/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1934 BLUFF CT
TROY MI
48098-6616
US

IV. Provider business mailing address

1934 BLUFF CT
TROY MI
48098-6616
US

V. Phone/Fax

Practice location:
  • Phone: 248-312-0005
  • Fax: 248-940-2949
Mailing address:
  • Phone: 248-312-0005
  • Fax: 248-940-2949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. REGINA C SHADE
Title or Position: CONSULTANT
Credential:
Phone: 586-260-2858