Healthcare Provider Details

I. General information

NPI: 1760708499
Provider Name (Legal Business Name): CLARKSTON URGENT CARE PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2010
Last Update Date: 08/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5701 BOW POINTE DR SUITE 120
CLARKSTON MI
48346-3198
US

IV. Provider business mailing address

5701 BOW POINTE DR SUITE 120
CLARKSTON MI
48346-3198
US

V. Phone/Fax

Practice location:
  • Phone: 248-625-2273
  • Fax: 248-625-6336
Mailing address:
  • Phone: 248-625-2273
  • Fax: 248-625-6336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number5101011134
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101009832
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301074879
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301048260
License Number StateMI
# 5
Primary TaxonomyN
Taxonomy Code2083P0500X
TaxonomyPreventive Medicine/Occupational Environmental Medicine Physician
License Number5101011123
License Number StateMI

VIII. Authorized Official

Name: TIMOTHY R ONEILL
Title or Position: PRESIDENT
Credential: DO
Phone: 248-625-2621