Healthcare Provider Details

I. General information

NPI: 1710065354
Provider Name (Legal Business Name): ST CLAIR SHORES OBSTETRICS AND GYNECOLOGY, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46591 ROMEO PLANK RD SUITE 225
MACOMB MI
48044-5742
US

IV. Provider business mailing address

19714 TEN MILE ROAD
ST CLAIR SHORES MI
48080
US

V. Phone/Fax

Practice location:
  • Phone: 586-226-6155
  • Fax: 586-226-6160
Mailing address:
  • Phone: 586-779-9400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. CONSTANTINE RAPHTIS
Title or Position: MEMBER
Credential: D.O
Phone: 586-779-9400