Provider Demographics
NPI:1891321352
Name:MUSKEGON PEDIATRICS, PLC
Entity Type:Organization
Organization Name:MUSKEGON PEDIATRICS, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:517-294-8741
Mailing Address - Street 1:16703 POND CRK
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49456-9792
Mailing Address - Country:US
Mailing Address - Phone:517-294-8741
Mailing Address - Fax:
Practice Address - Street 1:888 TERRACE ST
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49440-1220
Practice Address - Country:US
Practice Address - Phone:517-294-8741
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-17
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI802429468OtherCORPORATION LICENSING
MI1558591073OtherNPI
MI5315053660OtherSTATE LICENSE