Provider Demographics
NPI:1851568638
Name:HOLLYWOOD PEDITRIC CLINIC
Entity Type:Organization
Organization Name:HOLLYWOOD PEDITRIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:REKHA
Authorized Official - Middle Name:SUDHIR
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-771-2340
Mailing Address - Street 1:18811 E 10 MILE RD
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-3931
Mailing Address - Country:US
Mailing Address - Phone:586-771-2340
Mailing Address - Fax:586-771-7323
Practice Address - Street 1:18811 E 10 MILE RD
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-3931
Practice Address - Country:US
Practice Address - Phone:586-771-2340
Practice Address - Fax:586-771-7323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-12
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301045777208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty