1104878636 NPI number — MCLAREN MACOMB

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104878636 NPI number — MCLAREN MACOMB

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MCLAREN MACOMB
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104878636
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/23/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
32743 23 MILE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHESTERFIELD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48047-1985
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-725-9600
Provider Business Mailing Address Fax Number:
586-725-7170

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
32743 23 MILE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHESTERFIELD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48047
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-725-9600
Provider Business Practice Location Address Fax Number:
586-725-7170
Provider Enumeration Date:
05/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BRISSE
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
M
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
586-493-8083

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4853249 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4248827 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4344028 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4414033 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4463904 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3493533 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4283020 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4849193 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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