Provider Demographics
NPI:1619922176
Name:MICHIGAN PEDIATRIC CARDIOVASCULAR SURGEONS PC
Entity Type:Organization
Organization Name:MICHIGAN PEDIATRIC CARDIOVASCULAR SURGEONS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:LANE
Authorized Official - Last Name:WALTERS
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:313-745-5538
Mailing Address - Street 1:PO BOX 441097
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48244-1097
Mailing Address - Country:US
Mailing Address - Phone:313-745-5538
Mailing Address - Fax:313-993-0531
Practice Address - Street 1:3901 BEAUBIEN BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2119
Practice Address - Country:US
Practice Address - Phone:313-745-5538
Practice Address - Fax:313-993-0531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty