Provider Demographics
NPI:1467917955
Name:PEDIAKARE
Entity Type:Organization
Organization Name:PEDIAKARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DEVYANI
Authorized Official - Middle Name:
Authorized Official - Last Name:GUPTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-808-1299
Mailing Address - Street 1:3859 FADI DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-1584
Mailing Address - Country:US
Mailing Address - Phone:248-808-1299
Mailing Address - Fax:
Practice Address - Street 1:35240 NANKIN BLVD
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185-7218
Practice Address - Country:US
Practice Address - Phone:734-427-3636
Practice Address - Fax:734-427-1483
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-08
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty