Provider Demographics
NPI:1003482019
Name:GRACE PEDIATRICS PC
Entity Type:Organization
Organization Name:GRACE PEDIATRICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROY
Authorized Official - Middle Name:
Authorized Official - Last Name:PULLUKAT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-884-3879
Mailing Address - Street 1:44200 WOODWARD AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48341-5046
Mailing Address - Country:US
Mailing Address - Phone:248-253-9600
Mailing Address - Fax:248-253-0980
Practice Address - Street 1:44200 WOODWARD AVE STE 103
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-5046
Practice Address - Country:US
Practice Address - Phone:248-253-9600
Practice Address - Fax:248-253-0980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-01
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care