Provider Demographics
NPI:1700955739
Name:SG PEDIATRIC
Entity Type:Organization
Organization Name:SG PEDIATRIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICAIL
Authorized Official - Prefix:DR
Authorized Official - First Name:SRILAKSHMI
Authorized Official - Middle Name:
Authorized Official - Last Name:PINNAMARAJU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-662-4091
Mailing Address - Street 1:26850 PROVIDENCE PKWY
Mailing Address - Street 2:SUITE 320
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48374-1213
Mailing Address - Country:US
Mailing Address - Phone:248-662-4091
Mailing Address - Fax:
Practice Address - Street 1:26850 PROVIDENCE PKWY
Practice Address - Street 2:SUITE 320
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48374-1213
Practice Address - Country:US
Practice Address - Phone:248-662-4091
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2013-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4721230Medicaid
MI4534292Medicaid
MI4566240Medicaid
MI4721221Medicaid
MI4721230Medicaid