Healthcare Provider Details

I. General information

NPI: 1477620755
Provider Name (Legal Business Name): USCG CLINIC SECTOR DETROIT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43401 N. JEFFERSON, BLDG 825
SELFRIDGE ANGB MI
48045
US

IV. Provider business mailing address

43401 N. JEFFERSON, BLDG 825
SELFRIDGE ANGB MI
48045
US

V. Phone/Fax

Practice location:
  • Phone: 586-307-5017
  • Fax: 586-307-5010
Mailing address:
  • Phone: 586-307-5017
  • Fax: 586-307-5010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1100X
TaxonomyMilitary/U.S. Coast Guard Outpatient Clinic/Center
License Number4301062131
License Number StateMI

VIII. Authorized Official

Name: DR. JOSEPH P SIMON
Title or Position: CHIEF, HEALTH SERVICES DIVISION
Credential: M.D.
Phone: 586-307-5017