1508864620 NPI number — ST CLAIR ADULT MEDICINE SPECIALISTS PC

Table of content: (NPI 1508864620)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508864620 NPI number — ST CLAIR ADULT MEDICINE SPECIALISTS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST CLAIR ADULT MEDICINE SPECIALISTS PC
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:
1508864620
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/16/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 673215
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DETROIT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48267-3215
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-778-4080
Provider Business Mailing Address Fax Number:
586-778-6055

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
23411 JEFFERSON AVE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
SAINT CLAIR SHORES
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48080-1949
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-778-4080
Provider Business Practice Location Address Fax Number:
586-778-6055
Provider Enumeration Date:
07/12/2005

Additional Information

Authorized Official

Authorized Official Last Name:
HARDWICKE
Authorized Official First Name:
MARY
Authorized Official Middle Name:
BETH
Authorized Official Title or Position:
OWNER/PHYSICIAN
Authorized Official Telephone Number:
586-778-4080

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  MH404922 , 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: 4240936 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3389123 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 110E010920 . This is a "BCBS BCN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 3384323 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4613977 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4989630 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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