1093756934 NPI number — PORT HURON CLINIC P.C.

Table of content: (NPI 1093756934)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093756934 NPI number — PORT HURON CLINIC P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PORT HURON CLINIC P.C.
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:
1093756934
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/14/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 198
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHFIELD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48037-0198
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-569-5100
Provider Business Mailing Address Fax Number:
248-569-4774

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1107 STONE ST
Provider Second Line Business Practice Location Address:
STE #1
Provider Business Practice Location Address City Name:
PORT HURON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48060-3569
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-982-8300
Provider Business Practice Location Address Fax Number:
810-982-8308
Provider Enumeration Date:
06/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LEVIN
Authorized Official First Name:
MORTIMER
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
248-569-5100

Provider Taxonomy Codes

  • Taxonomy code: 173000000X , with the licence number:  003615 , 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)





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