Healthcare Provider Details

I. General information

NPI: 1285685339
Provider Name (Legal Business Name): MCLAREN MACOMB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2006
Last Update Date: 05/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36500 S GRATIOT AVE STE. 102
CLINTON TOWNSHIP MI
48035
US

IV. Provider business mailing address

36500 S GRATIOT AVE STE. 102
CLINTON TOWNSHIP MI
48035-1772
US

V. Phone/Fax

Practice location:
  • Phone: 586-790-9003
  • Fax: 586-493-3603
Mailing address:
  • Phone: 586-790-9003
  • Fax: 586-493-3603

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number5101014297
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number5101013302
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. THOMAS M BRISSE
Title or Position: CEO
Credential:
Phone: 586-493-8083