Healthcare Provider Details

I. General information

NPI: 1669837993
Provider Name (Legal Business Name): ST. CHARLES FAMILY CLINIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/31/2015
Last Update Date: 02/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 W BELLE AVENUE
SAINT CHARLES MI
48655
US

IV. Provider business mailing address

611 W BELLE AVE
SAINT CHARLES MI
48655-1611
US

V. Phone/Fax

Practice location:
  • Phone: 989-865-9958
  • Fax: 989-865-8099
Mailing address:
  • Phone: 989-865-9958
  • Fax: 989-865-8099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301059644
License Number StateMI

VIII. Authorized Official

Name: NAVEED MAHFOOZ
Title or Position: OWNER
Credential: MD
Phone: 989-865-9958