Basic Information
| Provider Information | |||||||||
| NPI: | 1487761664 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | MAIRA | ||||||||
| FirstName: | ROSA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5943 STADIUM DR | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490093016 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 8088 VINEYARD PKWY | ||||||||
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| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490093892 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2692867090 | ||||||||
| FaxNumber: | 2692867091 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2006 | ||||||||
| LastUpdateDate: | 10/19/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 5101014172 | MI | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.