Provider Demographics
NPI:1336353515
Name:PEDICENTER ASSOCIATES, P.C.
Entity Type:Organization
Organization Name:PEDICENTER ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:NATALIA
Authorized Official - Middle Name:M
Authorized Official - Last Name:TANNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-559-8336
Mailing Address - Street 1:20905 GREENFIELD RD
Mailing Address - Street 2:STE 207
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-5360
Mailing Address - Country:US
Mailing Address - Phone:248-559-8336
Mailing Address - Fax:248-559-8549
Practice Address - Street 1:20905 GREENFIELD RD
Practice Address - Street 2:STE 207
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-5360
Practice Address - Country:US
Practice Address - Phone:248-559-8336
Practice Address - Fax:248-559-8549
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI430(NT)1019821174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIF69601Medicare UPIN