Healthcare Provider Details

I. General information

NPI: 1043394877
Provider Name (Legal Business Name): SHENANDOAH CLINIC, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 02/24/2022
Certification Date: 02/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 W MAPLE RD SUITE 100
CLAWSON MI
48017-1000
US

IV. Provider business mailing address

909 W MAPLE RD SUITE 100
CLAWSON MI
48017-1000
US

V. Phone/Fax

Practice location:
  • Phone: 248-435-2028
  • Fax: 248-435-2099
Mailing address:
  • Phone: 248-435-2028
  • Fax: 248-435-2099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. RONALD I ROTHENBERG
Title or Position: PHYSICIAN/PRESIDENT
Credential: DO
Phone: 248-435-2028