Healthcare Provider Details

I. General information

NPI: 1093756934
Provider Name (Legal Business Name): PORT HURON CLINIC P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 08/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1107 STONE ST STE #1
PORT HURON MI
48060-3569
US

IV. Provider business mailing address

PO BOX 198
SOUTHFIELD MI
48037-0198
US

V. Phone/Fax

Practice location:
  • Phone: 810-982-8300
  • Fax: 810-982-8308
Mailing address:
  • Phone: 248-569-5100
  • Fax: 248-569-4774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number003615
License Number StateMI

VIII. Authorized Official

Name: MORTIMER LEVIN
Title or Position: DIRECTOR
Credential: DO
Phone: 248-569-5100