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General NPI Number Information
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NPI Number | 1104082148
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Entity Type | Organization
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Legal Business Name | WATERFORD PEDIATRICS
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Dates
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Enumeration Date | 07/30/2008
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Last Update Date | 07/30/2008
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Provider Practice Location Address
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Address Line | 4185 HIGHLAND RD
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City | WATERFORD
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State | MI
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Zip | 48328
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Country | US
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Telephone | 248-648-8930
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Fax | 248-648-8931
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Provider Business Mailing Address
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Address Line | 4185 HIGHLAND RD
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City | WATERFORD
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State | MI
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Zip | 48328
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Country | US
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Telephone | 248-648-8930
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Fax | 248-648-8931
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Authorized Official
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Title or Position | BILLING MGR
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Name | MRS. VICKI L INMAN
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Credential |
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Telephone | 248-666-4266
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | MK057394
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License Number State | MI
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