Healthcare Provider Details

I. General information

NPI: 1174665988
Provider Name (Legal Business Name): POLYCLINIC ASSOCIATES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26400 W 12 MILE RD STE 38
SOUTHFIELD MI
48034-1700
US

IV. Provider business mailing address

26400 W 12 MILE RD STE 38
SOUTHFIELD MI
48034-1700
US

V. Phone/Fax

Practice location:
  • Phone: 248-663-9846
  • Fax: 248-663-9854
Mailing address:
  • Phone: 248-663-9846
  • Fax: 248-663-9854

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number50011601
License Number StateMI

VIII. Authorized Official

Name: TOM BRUSSEAU
Title or Position: MGR
Credential:
Phone: 248-663-9846