Provider Demographics
NPI:1104082148
Name:WATERFORD PEDIATRICS
Entity type:Organization
Organization Name:WATERFORD PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MGR
Authorized Official - Prefix:MRS
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:L
Authorized Official - Last Name:INMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-666-4266
Mailing Address - Street 1:4185 HIGHLAND RD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48328
Mailing Address - Country:US
Mailing Address - Phone:248-648-8930
Mailing Address - Fax:248-648-8931
Practice Address - Street 1:4185 HIGHLAND RD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48328
Practice Address - Country:US
Practice Address - Phone:248-648-8930
Practice Address - Fax:248-648-8931
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-30
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMK057394208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4149524Medicaid
021121OtherMIDWEST
C7543OtherMCARE
0634011OtherBCBS
120911OtherCARECHOICES
15486OtherHEALTH PLAN
MI4149524Medicaid
MIOP13980Medicare PIN