Organization
SOUTHSIDE PEDIATRICS PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. CARRIE WILGUS MD (OWNER/PHYSICIAN)
(269) 818-1020
Entity
Organization
Contact information
Practice address
300 MEADOW RUN DR, HASTINGS, MI 49058-9048
(269) 818-1020
(269) 818-1266
Mailing address
300 MEADOW RUN DR, HASTINGS, MI 49058-9048
(269) 818-1020
(269) 818-1266
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
4301073703
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
4123869
—
MI
Enumeration date
07/17/2012
Last updated
12/20/2012
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