Provider Demographics
NPI:1124051990
Name:SHELBY PEDIATRIC ASSOCIATES AND CHILD LUNG CENTER PC
Entity type:Organization
Organization Name:SHELBY PEDIATRIC ASSOCIATES AND CHILD LUNG CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:PELLERITO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-532-0599
Mailing Address - Street 1:15125 22 MILE RD
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48315-4406
Mailing Address - Country:US
Mailing Address - Phone:586-532-0599
Mailing Address - Fax:586-566-8967
Practice Address - Street 1:15125 22 MILE RD
Practice Address - Street 2:
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48315-4406
Practice Address - Country:US
Practice Address - Phone:586-532-0599
Practice Address - Fax:586-566-8967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAR2460549208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4669589Medicaid
MI4432864Medicaid
MI4432882Medicaid
MII22529Medicare UPIN
MI4669589Medicaid
MI4432882Medicaid