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General NPI Number Information
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NPI Number | 1801453287
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Entity Type | Organization
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Legal Business Name | PEDIATRIC CARDIOLOGY OF SOUTHEASTREN MICHIGAN
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Dates
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Enumeration Date | 05/21/2019
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Last Update Date | 05/21/2019
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Provider Practice Location Address
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Address Line | 1934 BLUFF CT
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City | TROY
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State | MI
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Zip | 48098-6616
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Country | US
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Telephone | 248-312-0005
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Fax | 248-940-2949
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Provider Business Mailing Address
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Address Line | 1934 BLUFF CT
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City | TROY
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State | MI
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Zip | 48098-6616
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Country | US
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Telephone | 248-312-0005
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Fax | 248-940-2949
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Authorized Official
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Title or Position | CONSULTANT
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Name | MRS. REGINA C SHADE
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Credential |
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Telephone | 586-260-2858
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2080P0202X
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Taxonomy Name | Pediatric Cardiology Physician
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License Number |
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License Number State |
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