Provider Demographics
NPI:1730187840
Name:MY KIDS DOC-SOUTHFIELD
Entity type:Organization
Organization Name:MY KIDS DOC-SOUTHFIELD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-358-2410
Mailing Address - Street 1:PO BOX 33321
Mailing Address - Street 2:DRAWER 117
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48232-5321
Mailing Address - Country:US
Mailing Address - Phone:248-358-2410
Mailing Address - Fax:248-358-2470
Practice Address - Street 1:29255 NORTHWESTERN HWY
Practice Address - Street 2:SUITE 100
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1018
Practice Address - Country:US
Practice Address - Phone:248-358-2410
Practice Address - Fax:248-358-2470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-12
Last Update Date:2009-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIPB0478772080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI350F300680OtherBCN GROUP
MI1730187840Medicaid
MI350F300680OtherBCBS GROUP