# MICHIGAN PEDIATRIC CARDIOVASCULAR SURGEONS PC

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

## Provider details

- **NPI number:** 1619922176
- **Authorized official:** DR. HENRY LANE WALTERS III M.D. (PRESIDENT)
- **Authorized official phone:** (313) 745-5538

## Contact information

- **Practice address:** 3901 BEAUBIEN BLVD, DETROIT, MI 48201-2119
- **Practice address phone:** (313) 745-5538
- **Practice address fax:** (313) 993-0531
- **Mailing address:** PO BOX 441097, DETROIT, MI 48244-1097
- **Mailing address phone:** (313) 745-5538
- **Mailing address fax:** (313) 993-0531

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 208G00000X | Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician | — | NULL | Yes |
| 208G00000X | Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician | — | — | Yes |

## Other

- **Enumeration date:** 05/23/2006
- **Last updated:** 08/22/2020