Provider Demographics
NPI:1265421069
Name:PEDIATRICS PC
Entity type:Organization
Organization Name:PEDIATRICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:R
Authorized Official - Last Name:LULL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:269-327-1900
Mailing Address - Street 1:670 MALL DR
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-2878
Mailing Address - Country:US
Mailing Address - Phone:269-327-1900
Mailing Address - Fax:269-327-1564
Practice Address - Street 1:670 MALL DR
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-2878
Practice Address - Country:US
Practice Address - Phone:269-327-1900
Practice Address - Fax:269-327-1564
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty