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General NPI Number Information
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NPI Number | 1063719292
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Entity Type | Organization
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Legal Business Name | ST CLAIR SPECIALTY PHYSICIANS
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Dates
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Enumeration Date | 02/24/2011
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Last Update Date | 02/24/2011
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Provider Practice Location Address
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Address Line | 5610 GAGE STREET SUITE A
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City | BOISE
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State | ID
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Zip | 83706
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Country | US
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Telephone | 208-367-3370
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Fax |
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Provider Business Mailing Address
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Address Line | 45640 SCHOENHERR ROAD
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City | SHELBY TWP
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State | MI
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Zip | 48315
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Country | US
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Telephone | 586-247-4300
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Fax | 586-532-6496
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Authorized Official
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Title or Position | PRESIDENT/PARTNER
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Name | ROBERT PROVENZANO
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Credential | MD
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Telephone | 313-886-8787
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RN0300X
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Taxonomy Name | Nephrology Physician
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License Number |
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License Number State |
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