# WATERFORD PEDIATRICS

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1104082148
- **Authorized official:** MRS. VICKI L INMAN (BILLING MGR)
- **Authorized official phone:** (248) 666-4266

## Contact information

- **Practice address:** 4185 HIGHLAND RD, WATERFORD, MI 48328
- **Practice address phone:** (248) 648-8930
- **Practice address fax:** (248) 648-8931
- **Mailing address:** 4185 HIGHLAND RD, WATERFORD, MI 48328
- **Mailing address phone:** (248) 648-8930
- **Mailing address fax:** (248) 648-8931

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 208D00000X | General Practice Physician | MK057394 | MI | Yes |

## Other

- **Enumeration date:** 07/30/2008
- **Last updated:** 07/30/2008

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 021121 | MIDWEST | — |
| 01 | — | 0634011 | BCBS | — |
| 01 | — | 120911 | CARECHOICES | — |
| 01 | — | 15486 | HEALTH PLAN | — |
| 05 | — | 4149524 | — | MI |
| 01 | — | C7543 | MCARE | — |