1093756934 NPI number — PORT HURON CLINIC P.C.

Table of content: JOSEPH KALEO MARSHALL JR. (NPI 1114893880)

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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