Provider Demographics
NPI:1841463577
Name:MID MICHIGAN PEDIATRIC CARDIOLOGY, PC
Entity type:Organization
Organization Name:MID MICHIGAN PEDIATRIC CARDIOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SALLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:LECLAIR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-752-8669
Mailing Address - Street 1:900 COOPER AVE
Mailing Address - Street 2:SUITE #4200
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48602-5182
Mailing Address - Country:US
Mailing Address - Phone:989-752-8669
Mailing Address - Fax:989-752-4844
Practice Address - Street 1:900 COOPER AVE
Practice Address - Street 2:SUITE #4200
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-5182
Practice Address - Country:US
Practice Address - Phone:989-752-8669
Practice Address - Fax:989-752-4844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-02
Last Update Date:2009-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301063051174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3507344422OtherBCBS OF MICHIGAN
MI4180201Medicaid
MI3507344422OtherBLUE CARE NETWORK