Provider Demographics
NPI:1508864687
Name:PEDIATRIC CARE CORNER PC
Entity Type:Organization
Organization Name:PEDIATRIC CARE CORNER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CONSTANCE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROWLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:248-926-1411
Mailing Address - Street 1:PO BOX 33321
Mailing Address - Street 2:DRAWER 95
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48232-5321
Mailing Address - Country:US
Mailing Address - Phone:248-926-1411
Mailing Address - Fax:248-926-5338
Practice Address - Street 1:2300 HAGGERTY RD
Practice Address - Street 2:SUITE 2110
Practice Address - City:W BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48323-2184
Practice Address - Country:US
Practice Address - Phone:248-926-1411
Practice Address - Fax:248-926-5338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-12
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MICR0102952080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI350F375630OtherBCBC BCN
MI0N96030Medicare PIN