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General NPI Number Information
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NPI Number | 1730187840
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Entity Type | Organization
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Legal Business Name | MY KIDS DOC-SOUTHFIELD
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Dates
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Enumeration Date | 07/12/2005
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Last Update Date | 04/29/2009
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Provider Practice Location Address
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Address Line | 29255 NORTHWESTERN HWY SUITE 100
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City | SOUTHFIELD
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State | MI
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Zip | 48034-1018
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Country | US
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Telephone | 248-358-2410
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Fax | 248-358-2470
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Provider Business Mailing Address
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Address Line | PO BOX 33321 DRAWER 117
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City | DETROIT
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State | MI
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Zip | 48232-5321
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Country | US
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Telephone | 248-358-2410
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Fax | 248-358-2470
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Authorized Official
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Title or Position | OWNER/PHYSICIAN
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Name | DR. PAMELA BERRY
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Credential | MD
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Telephone | 248-358-2410
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2080A0000X
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Taxonomy Name | Pediatric Adolescent Medicine Physician
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License Number | PB047877
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License Number State | MI
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