Provider Demographics
NPI:1932229382
Name:J & I PEDIATRIC CARE CENTER
Entity Type:Organization
Organization Name:J & I PEDIATRIC CARE CENTER
Other - Org Name:PEDIATRIC CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MANAL
Authorized Official - Middle Name:N
Authorized Official - Last Name:HADDAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-841-1680
Mailing Address - Street 1:9720 DIX
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48120-1566
Mailing Address - Country:US
Mailing Address - Phone:313-841-1680
Mailing Address - Fax:
Practice Address - Street 1:9720 DIX
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48120-1566
Practice Address - Country:US
Practice Address - Phone:313-841-1680
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI350H211870OtherBCBSM GROUP NUMBER