Provider Demographics
NPI:1285920462
Name:MY SECOND HOME PEDIATRICS PLLC
Entity type:Organization
Organization Name:MY SECOND HOME PEDIATRICS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:KALPANA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-865-0030
Mailing Address - Street 1:31000 TELEGRAPH RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BINGHAM FARMS
Mailing Address - State:MI
Mailing Address - Zip Code:48025-4360
Mailing Address - Country:US
Mailing Address - Phone:248-865-0030
Mailing Address - Fax:
Practice Address - Street 1:31000 TELEGRAPH RD
Practice Address - Street 2:SUTIE 100
Practice Address - City:BINGHAM FARMS
Practice Address - State:MI
Practice Address - Zip Code:48025-4360
Practice Address - Country:US
Practice Address - Phone:248-865-0030
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-25
Last Update Date:2011-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2732113208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3289496Medicaid
MIA78426Medicare UPIN