1750327771 NPI number — CLARKSTON HEALTH CENTER

Table of content: (NPI 1750327771)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750327771 NPI number — CLARKSTON HEALTH CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLARKSTON HEALTH CENTER
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:
1750327771
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5625 WATER TOWER PL
Provider Second Line Business Mailing Address:
SUITE G-33
Provider Business Mailing Address City Name:
CLARKSTON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48346-2671
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-620-4222
Provider Business Mailing Address Fax Number:
248-620-4234

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5625 WATER TOWER PL
Provider Second Line Business Practice Location Address:
SUITE G-33
Provider Business Practice Location Address City Name:
CLARKSTON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48346-2671
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-620-4222
Provider Business Practice Location Address Fax Number:
248-620-4234
Provider Enumeration Date:
06/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
THOMAS
Authorized Official First Name:
KELLI
Authorized Official Middle Name:
K
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
248-620-4227

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  775305 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000009522 . This is a "CAPE MEDICAL" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: ON75750 . This is a "HAP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 137850 . This is a "CARE CHOICES" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: OF30168 . This is a "BLUE CARE NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: OF30168 . This is a "BLUE CROSS BLUE SHIELD OF" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0996948 . This is a "HEALTH PLUS OF MI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 137850 . This is a "PREFERRED CHOICES" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 16442 . This is a "M-CARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 7065650 . This is a "CIGNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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