Provider Demographics
NPI:1356440572
Name:CENTER FOR PEDIATRIC & ADOLESCENT MEDICINE
Entity Type:Organization
Organization Name:CENTER FOR PEDIATRIC & ADOLESCENT MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:T
Authorized Official - Last Name:MULLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-816-1300
Mailing Address - Street 1:2100 W BIG BEAVER
Mailing Address - Street 2:STE 110
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084
Mailing Address - Country:US
Mailing Address - Phone:248-816-1300
Mailing Address - Fax:248-816-0088
Practice Address - Street 1:2100 W BIG BEAVER
Practice Address - Street 2:STE 110
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084
Practice Address - Country:US
Practice Address - Phone:248-816-1300
Practice Address - Fax:248-816-0088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0740000Medicare ID - Type Unspecified