Healthcare Provider Details

I. General information

NPI: 1255306114
Provider Name (Legal Business Name): WEST BRANCH PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

337 EAST HOUGHTON AVE
WEST BRANCH MI
48661
US

IV. Provider business mailing address

PO BOX 295 337 EAST HOUGHTON AVE
WEST BRANCH MI
48661
US

V. Phone/Fax

Practice location:
  • Phone: 989-343-9466
  • Fax: 989-343-9443
Mailing address:
  • Phone: 989-343-9466
  • Fax: 989-343-9443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301085011
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301085012
License Number StateMI

VIII. Authorized Official

Name: JOHNIE C BAKER
Title or Position: OWNER
Credential: MD
Phone: 989-343-9466