Healthcare Provider Details

I. General information

NPI: 1083669691
Provider Name (Legal Business Name): MCLAREN MACOMB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 05/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 HARRINGTON BLVD. ATTN: SPECIAL CARE NURSERY
MT. CLEMENS MI
48043
US

IV. Provider business mailing address

1000 HARRINGTON BLVD. ATTN: SPECIAL CARE NURSERY
MT. CLEMENS MI
48043-2920
US

V. Phone/Fax

Practice location:
  • Phone: 586-493-8296
  • Fax: 586-741-4114
Mailing address:
  • Phone: 586-493-8296
  • Fax: 586-741-4114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301085002
License Number StateMI

VIII. Authorized Official

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