Provider Demographics
NPI:1194997825
Name:PEDIATRICS PRIMARY CARE PLLC
Entity type:Organization
Organization Name:PEDIATRICS PRIMARY CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRICIAN
Authorized Official - Prefix:
Authorized Official - First Name:BUENAVENTURA
Authorized Official - Middle Name:CARMEN
Authorized Official - Last Name:PEREYRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-530-2846
Mailing Address - Street 1:4433 BYRON CENTER AVE SW
Mailing Address - Street 2:PEDIATRICS PRIMARY CARE
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:616-530-2854
Practice Address - Street 1:4433 BYRON CENTER AVE SW
Practice Address - Street 2:PEDIATRICS PRIMARY CARE
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519
Practice Address - Country:US
Practice Address - Phone:616-530-2846
Practice Address - Fax:616-530-2854
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-02
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301066298261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
D99550Medicare UPIN