Basic Information
| Provider Information | |||||||||
| NPI: | 1164742110 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHERIAN | ||||||||
| FirstName: | BETSY | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PHILIP | ||||||||
| OtherFirstName: | BETSY | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 559 W GRAND BLVD | ||||||||
| Address2: | COVENANT COMMUNITY CARE | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482162200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3132280217 | ||||||||
| FaxNumber: | 3032280204 | ||||||||
| Practice Location | |||||||||
| Address1: | 5716 MICHIGAN AVE | ||||||||
| Address2: | COVENANT COMMUNITY CARE | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482103039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3135541095 | ||||||||
| FaxNumber: | 3135541096 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2010 | ||||||||
| LastUpdateDate: | 07/26/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 4301099504 | MI | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.