Basic Information
| Provider Information | |||||||||
| NPI: | 1801001771 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BARTAKIAN | ||||||||
| FirstName: | SERGIO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | UNIVERSITY PEDIATRICIANS | ||||||||
| Address2: | 4201 ST. ANTOINE UHC 5D # 226 | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3139665051 | ||||||||
| FaxNumber: | 3139660665 | ||||||||
| Practice Location | |||||||||
| Address1: | CHILDREN'S HOSPITAL OF MI - 4TH | ||||||||
| Address2: | 3901 BEAUBIEN | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3137455481 | ||||||||
| FaxNumber: | 3139662423 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2007 | ||||||||
| LastUpdateDate: | 07/23/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0202X | A121219 | CA | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology | 2080P0202X | 47596 | CO | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology | 208000000X | 57.011456 | OH | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 4301119342 | MI | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0202X | P7881 | TX | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology | 2080P0202X | 4301119342 | MI | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 329070204 | 01 | TX | CSHCN | OTHER | 329070203 | 05 | TX | MEDICAID |