Healthcare Provider Details

I. General information

NPI: 1285974790
Provider Name (Legal Business Name): SAINT JOSEPH CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2013
Last Update Date: 02/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23077 GREENFIELD RD SUITE#240
SOUTHFIELD MI
48075-3709
US

IV. Provider business mailing address

23077 GREENFIELD RD SUITE#240
SOUTHFIELD MI
48075-3709
US

V. Phone/Fax

Practice location:
  • Phone: 248-809-6402
  • Fax: 248-537-3012
Mailing address:
  • Phone: 248-809-6402
  • Fax: 248-537-3012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. SRINIVASULU REDDY
Title or Position: ADMINISTRATOR
Credential:
Phone: 248-809-6402