1912228743 NPI number — CLIFFORD L WELDON M D P L C

Table of content: (NPI 1912228743)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912228743 NPI number — CLIFFORD L WELDON M D P L C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLIFFORD L WELDON M D P L 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:
1912228743
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/28/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
30695 LITTLE MACK AVE STE 500
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROSEVILLE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48066-1772
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-285-9270
Provider Business Mailing Address Fax Number:
586-285-9271

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15945 19 MILE RD STE 202
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLINTON TOWNSHIP
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48038-1147
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-285-9270
Provider Business Practice Location Address Fax Number:
586-285-9271
Provider Enumeration Date:
06/16/2010

Additional Information

Authorized Official

Authorized Official Last Name:
WELDON
Authorized Official First Name:
CLIFFORD
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PHYSICIAN/OWNER
Authorized Official Telephone Number:
586-285-9270

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  CW054557 , 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: QMXPR0020661 . This is a "MOLINA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0500966 . This is a "BCBSM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: CW054557 . This is a "LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 7001298 . This is a "CHAMPS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: M-006492 . This is a "TRICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: P87524 . This is a "BCN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0166726 . This is a "TOTAL HEALTHCARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1528194545 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 21606 . This is a "OMNICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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