Provider Demographics
NPI:1417054594
Name:CHILDREN'S HEART CENTER, PC
Entity Type:Organization
Organization Name:CHILDREN'S HEART CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PEDIATRIC CARDIOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:N
Authorized Official - Last Name:MATISOFF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:517-484-0004
Mailing Address - Street 1:1514 E MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48912-2221
Mailing Address - Country:US
Mailing Address - Phone:517-484-0004
Mailing Address - Fax:517-484-7241
Practice Address - Street 1:1514 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-2221
Practice Address - Country:US
Practice Address - Phone:517-484-0004
Practice Address - Fax:517-484-7241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIDM040001174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI350C31064OtherBCBS OF MI GROUP ID