Healthcare Provider Details

I. General information

NPI: 1073385738
Provider Name (Legal Business Name): ST. CLAIR ORTHOPAEDICS AND SPORTS MEDICINE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2023
Last Update Date: 10/26/2023
Certification Date: 10/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23829 LITTLE MACK AVE STE 100
SAINT CLAIR SHORES MI
48080-1186
US

IV. Provider business mailing address

23829 LITTLE MACK AVE STE 100
SAINT CLAIR SHORES MI
48080-1186
US

V. Phone/Fax

Practice location:
  • Phone: 586-773-1300
  • Fax:
Mailing address:
  • Phone: 586-773-1300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: ELAINE RUSSETTE
Title or Position: CREDENTIALING
Credential:
Phone: 586-552-4573