Healthcare Provider Details

I. General information

NPI: 1417126715
Provider Name (Legal Business Name): GREAT LAKES PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2008
Last Update Date: 02/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26000 HOOVER RD 103
WARREN MI
48089-1167
US

IV. Provider business mailing address

26000 HOOVER RD 103
WARREN MI
48089-1167
US

V. Phone/Fax

Practice location:
  • Phone: 586-427-1351
  • Fax:
Mailing address:
  • Phone: 586-427-1351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number4301073962
License Number StateMI

VIII. Authorized Official

Name: DR. SUNDUS RUMMANI-ASKAR
Title or Position: PRESIDENT
Credential: M.D.
Phone: 586-427-1351