MEDICARE: DETROIT RIVERVIEW PEDIATRICS PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician

General Provider Information

NPI Number	:	1417121252
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DETROIT RIVERVIEW PEDIATRICS PC

Provider Business Mailing Address
First Line	:	DEPT 999360 PO BOX 33738
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48232-3738
Country	:	US
Telephone Number	:	810-720-5715
Fax Number	:	810-732-0891

Provider Business Practice Location Address
First Line	:	10201 E JEFFERSON AVE
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48214-3149
Country	:	US
Telephone Number	:	313-821-3777
Fax Number	:	313-824-3777

Authorized Official
Title or Position	:	OWNER
Name	:	GERARD MOSBY
Credential	:
Telephone Number	:	313-821-3777

Provider Enumeration Date	:	04/14/2008
Last Update Date	:	11/12/2015

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