Provider Demographics
NPI:1740790146
Name:THEO PEDIATRIC HEALTH
Entity Type:Organization
Organization Name:THEO PEDIATRIC HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:LOREN
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:612-840-4156
Mailing Address - Street 1:PO BOX 43
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:MI
Mailing Address - Zip Code:48854-0043
Mailing Address - Country:US
Mailing Address - Phone:517-604-6177
Mailing Address - Fax:517-604-6184
Practice Address - Street 1:1219 1/2 TURNER ST
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48906-4341
Practice Address - Country:US
Practice Address - Phone:612-840-4156
Practice Address - Fax:888-859-9497
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-11
Last Update Date:2017-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301103705208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty