Healthcare Provider Details

I. General information

NPI: 1124148515
Provider Name (Legal Business Name): MCLAREN MACOMB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 05/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36500 S GRATIOT AVE SUITE 102
CLINTON TOWNSHIP MI
48035
US

IV. Provider business mailing address

401 S BALLENGER HWY
FLINT MI
48532-3638
US

V. Phone/Fax

Practice location:
  • Phone: 586-790-9003
  • Fax: 586-493-3603
Mailing address:
  • Phone: 810-342-1000
  • Fax: 810-342-1590

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

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