1013188648 NPI number — BRENTWOOD PEDIATRICS PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013188648 NPI number — BRENTWOOD PEDIATRICS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRENTWOOD PEDIATRICS PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013188648
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/23/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
33215 W. SEVEN MILE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LIVONIA
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48152
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-478-3200
Provider Business Mailing Address Fax Number:
248-478-3316

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
33215 W. SEVEN
Provider Second Line Business Practice Location Address:
BRENTWOOD PEDIATRICS ASSOCIATES
Provider Business Practice Location Address City Name:
LIVONIA
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48152
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-478-3200
Provider Business Practice Location Address Fax Number:
248-478-3316
Provider Enumeration Date:
03/24/2008

Additional Information

Authorized Official

Authorized Official Last Name:
GODBOLE
Authorized Official First Name:
AJEY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
248-478-3200

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  005826 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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