Provider Demographics
NPI:1457893430
Name:BRANCH PEDIATRICS
Entity Type:Organization
Organization Name:BRANCH PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MEHALAI
Authorized Official - Middle Name:
Authorized Official - Last Name:ARIVOLI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:517-924-1465
Mailing Address - Street 1:390 E CHICAGO ST
Mailing Address - Street 2:
Mailing Address - City:COLDWATER
Mailing Address - State:MI
Mailing Address - Zip Code:49036-2062
Mailing Address - Country:US
Mailing Address - Phone:517-924-1465
Mailing Address - Fax:517-924-1467
Practice Address - Street 1:390 E CHICAGO ST
Practice Address - Street 2:
Practice Address - City:COLDWATER
Practice Address - State:MI
Practice Address - Zip Code:49036-2062
Practice Address - Country:US
Practice Address - Phone:517-924-1465
Practice Address - Fax:517-924-1467
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-08
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301077145261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1497130132Medicaid