Healthcare Provider Details

I. General information

NPI: 1467917955
Provider Name (Legal Business Name): PEDIAKARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2019
Last Update Date: 09/30/2020
Certification Date: 09/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35240 NANKIN BLVD
WESTLAND MI
48185-7218
US

IV. Provider business mailing address

3859 FADI DR
TROY MI
48084-1584
US

V. Phone/Fax

Practice location:
  • Phone: 734-427-3636
  • Fax: 734-427-1483
Mailing address:
  • Phone: 248-808-1299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DEVYANI GUPTA
Title or Position: DIRECTOR
Credential: MD
Phone: 248-808-1299