Healthcare Provider Details

I. General information

NPI: 1093602229
Provider Name (Legal Business Name): ELITE PROVIDER GROUP PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2025
Last Update Date: 09/04/2025
Certification Date: 09/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5900 WALDON RD STE A
CLARKSTON MI
48346-4806
US

IV. Provider business mailing address

3495 S CENTER RD
BURTON MI
48519-1455
US

V. Phone/Fax

Practice location:
  • Phone: 248-625-7890
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: CRYSTAL CHANDLER
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 810-424-2136