Provider Demographics
NPI:1477781169
Name:PARKSIDE PEDIATRIC CLINIC,P.C.
Entity Type:Organization
Organization Name:PARKSIDE PEDIATRIC CLINIC,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KATIKINENI
Authorized Official - Middle Name:V
Authorized Official - Last Name:RAO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:517-787-4332
Mailing Address - Street 1:2100 4TH ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49203-4518
Mailing Address - Country:US
Mailing Address - Phone:517-787-4332
Mailing Address - Fax:517-787-4861
Practice Address - Street 1:2100 4TH ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49203-4518
Practice Address - Country:US
Practice Address - Phone:517-787-4332
Practice Address - Fax:517-787-4861
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-01
Last Update Date:2009-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301 031905208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1379549Medicaid
MI1379549Medicaid