Provider Demographics
NPI:1801453287
Name:PEDIATRIC CARDIOLOGY OF SOUTHEASTREN MICHIGAN
Entity type:Organization
Organization Name:PEDIATRIC CARDIOLOGY OF SOUTHEASTREN MICHIGAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONSULTANT
Authorized Official - Prefix:MRS
Authorized Official - First Name:REGINA
Authorized Official - Middle Name:C
Authorized Official - Last Name:SHADE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-260-2858
Mailing Address - Street 1:1934 BLUFF CT
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48098-6616
Mailing Address - Country:US
Mailing Address - Phone:248-312-0005
Mailing Address - Fax:248-940-2949
Practice Address - Street 1:1934 BLUFF CT
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48098-6616
Practice Address - Country:US
Practice Address - Phone:248-312-0005
Practice Address - Fax:248-940-2949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-21
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric CardiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1770551301Medicaid
MI1316244304Medicaid