Provider Demographics
NPI:1962003566
Name:BLUE WATER CHILDREN'S HEALTH CARE
Entity Type:Organization
Organization Name:BLUE WATER CHILDREN'S HEALTH CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:DEV
Authorized Official - Middle Name:
Authorized Official - Last Name:NANDAMUDI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:810-385-9559
Mailing Address - Street 1:3030 COMMERCE DR
Mailing Address - Street 2:
Mailing Address - City:FORT GRATIOT
Mailing Address - State:MI
Mailing Address - Zip Code:48059-3819
Mailing Address - Country:US
Mailing Address - Phone:810-385-9559
Mailing Address - Fax:810-385-9515
Practice Address - Street 1:3030 COMMERCE DR
Practice Address - Street 2:
Practice Address - City:FORT GRATIOT
Practice Address - State:MI
Practice Address - Zip Code:48059-3819
Practice Address - Country:US
Practice Address - Phone:810-385-9559
Practice Address - Fax:810-385-9515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-02
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty