Provider Demographics
NPI:1346428315
Name:PEDIATRIC & ADOLESCENT HEALTHCARE ASSOCIATES, PC
Entity Type:Organization
Organization Name:PEDIATRIC & ADOLESCENT HEALTHCARE ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:NIDIFFER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:906-225-3925
Mailing Address - Street 1:1414 W FAIR AVE
Mailing Address - Street 2:SUITE 226
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-2675
Mailing Address - Country:US
Mailing Address - Phone:906-225-3925
Mailing Address - Fax:906-225-4838
Practice Address - Street 1:1414 W FAIR AVE
Practice Address - Street 2:SUITE 226
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-2675
Practice Address - Country:US
Practice Address - Phone:906-225-3925
Practice Address - Fax:906-225-4838
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-01
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI030113174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3108394Medicaid
MI3108394Medicaid