=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013188648
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRENTWOOD PEDIATRICS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/24/2008
-----------------------------------------------------
Last Update Date | 02/23/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 33215 W. SEVEN BRENTWOOD PEDIATRICS ASSOCIATES
-----------------------------------------------------
City | LIVONIA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48152
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-478-3200
-----------------------------------------------------
Fax | 248-478-3316
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 33215 W. SEVEN MILE RD
-----------------------------------------------------
City | LIVONIA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48152
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-478-3200
-----------------------------------------------------
Fax | 248-478-3316
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | AJEY GODBOLE
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 248-478-3200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 005826
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------