Provider Demographics
NPI:1073010625
Name:VERNOR PEDIATRIC PC
Entity type:Organization
Organization Name:VERNOR PEDIATRIC PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CPC
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:BALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-839-6610
Mailing Address - Street 1:26206 W 12 MILE RD STE 106
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-1799
Mailing Address - Country:US
Mailing Address - Phone:248-354-1600
Mailing Address - Fax:248-354-1604
Practice Address - Street 1:4607 W VERNOR HWY
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48209-2117
Practice Address - Country:US
Practice Address - Phone:313-554-3300
Practice Address - Fax:313-554-3303
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KARMO PEDIATRIC CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-04-10
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MINK0696552080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty