Provider Demographics
NPI:1275558926
Name:CLYDE PARK PEDIATRICS, P.C.
Entity Type:Organization
Organization Name:CLYDE PARK PEDIATRICS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FLOR
Authorized Official - Middle Name:
Authorized Official - Last Name:BORRERO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-808-3265
Mailing Address - Street 1:3637 CLYDE PARK AVE SW STE 4
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49509
Mailing Address - Country:US
Mailing Address - Phone:616-808-3265
Mailing Address - Fax:616-726-7019
Practice Address - Street 1:3637 CLYDE PARK AVE SW STE 4
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49509
Practice Address - Country:US
Practice Address - Phone:616-808-3265
Practice Address - Fax:616-726-7019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208000000X
MI4301066741208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
D48289Medicare UPIN