Provider Demographics
NPI:1992937148
Name:HILLSDALE PEDIATRICS CLINIC PC
Entity type:Organization
Organization Name:HILLSDALE PEDIATRICS CLINIC PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SACKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:517-437-8325
Mailing Address - Street 1:1131 N OSSEO RD
Mailing Address - Street 2:P.O. BOX 187
Mailing Address - City:HILLSDALE
Mailing Address - State:MI
Mailing Address - Zip Code:49242-9714
Mailing Address - Country:US
Mailing Address - Phone:517-523-3695
Mailing Address - Fax:517-523-3311
Practice Address - Street 1:451 HIDDEN MEADOWS DR
Practice Address - Street 2:SUITE 200
Practice Address - City:HILLSDALE
Practice Address - State:MI
Practice Address - Zip Code:49242-9812
Practice Address - Country:US
Practice Address - Phone:517-437-8325
Practice Address - Fax:517-437-8327
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-20
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMS0869602080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
3503013872OtherBCBSM
MI105336218Medicaid
3503013872OtherBCBSM