Provider Demographics
NPI:1386204022
Name:PEDIATRIC CARDIOLOGY OF SOUTHEASTREN MICHIGAN, PLLC
Entity Type:Organization
Organization Name:PEDIATRIC CARDIOLOGY OF SOUTHEASTREN MICHIGAN, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROSSITZA
Authorized Official - Middle Name:PROKOPIEVA
Authorized Official - Last Name:PIRONKOVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-335-8500
Mailing Address - Street 1:43380 WOODWARD AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48302-5050
Mailing Address - Country:US
Mailing Address - Phone:248-335-8500
Mailing Address - Fax:248-940-2949
Practice Address - Street 1:43380 WOODWARD AVE STE 105
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302-5050
Practice Address - Country:US
Practice Address - Phone:248-335-8500
Practice Address - Fax:248-940-2949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-14
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric CardiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1316244304Medicaid