Healthcare Provider Details

I. General information

NPI: 1154361616
Provider Name (Legal Business Name): ST CLAIR SPECIALTY PHYSICIANS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 10/17/2022
Certification Date: 10/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18001 E 10 MILE RD SUITE 1
ROSEVILLE MI
48066-3803
US

IV. Provider business mailing address

45640 SCHOENHERR RD
SHELBY TOWNSHIP MI
48315-6033
US

V. Phone/Fax

Practice location:
  • Phone: 586-218-5800
  • Fax: 586-532-6496
Mailing address:
  • Phone: 586-247-4300
  • Fax: 586-532-6496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. CHRISTOPHER ROBERT PROVENZANO
Title or Position: CEO/MANAGING EMPLOYEE (W2)
Credential: MD
Phone: 586-286-7800