Provider Demographics
NPI:1518056340
Name:PEDIATRIC PHYSICIANS OF LANSING
Entity Type:Organization
Organization Name:PEDIATRIC PHYSICIANS OF LANSING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:D
Authorized Official - Last Name:ISREAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-371-4719
Mailing Address - Street 1:DEPT CH 17787
Mailing Address - Street 2:
Mailing Address - City:PALATINE
Mailing Address - State:IL
Mailing Address - Zip Code:60055-0001
Mailing Address - Country:US
Mailing Address - Phone:800-968-6866
Mailing Address - Fax:616-532-7230
Practice Address - Street 1:1200 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-1800
Practice Address - Country:US
Practice Address - Phone:517-364-5422
Practice Address - Fax:517-364-5439
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIXX00077OtherHEALTHPLUS
MI1230630001OtherWELLNESS
MI0P33004OtherMCARE
MI700C36031OtherBCBS
MIXX00077OtherHEALTHPLUS