Provider Demographics
NPI:1174691547
Name:PEDIATRIC HOLISTIC MEDICINE, PLC
Entity type:Organization
Organization Name:PEDIATRIC HOLISTIC MEDICINE, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCREADIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:734-213-0255
Mailing Address - Street 1:2350 WASHTENAW AVE
Mailing Address - Street 2:STE 24
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-4532
Mailing Address - Country:US
Mailing Address - Phone:734-213-0255
Mailing Address - Fax:734-213-0241
Practice Address - Street 1:2350 WASHTENAW AVE
Practice Address - Street 2:STE 24
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-4532
Practice Address - Country:US
Practice Address - Phone:734-213-0255
Practice Address - Fax:734-213-0241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3506345401OtherBCBS