Healthcare Provider Details

I. General information

NPI: 1649629924
Provider Name (Legal Business Name): HOLLY MARIE RADCLIFFE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2016
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4160 JOHN R ST
DETROIT MI
48201-2020
US

IV. Provider business mailing address

4160 JOHN R ST
DETROIT MI
48201-2020
US

V. Phone/Fax

Practice location:
  • Phone: 313-745-7247
  • Fax:
Mailing address:
  • Phone: 313-745-2535
  • Fax: 313-745-2777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601007781
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: