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General NPI Number Information
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NPI Number | 1154361616
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Entity Type | Organization
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Legal Business Name | ST CLAIR SPECIALTY PHYSICIANS PC
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Dates
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Enumeration Date | 06/06/2006
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Last Update Date | 10/17/2022
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Provider Practice Location Address
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Address Line | 18001 E 10 MILE RD SUITE 1
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City | ROSEVILLE
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State | MI
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Zip | 48066-3803
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Country | US
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Telephone | 586-218-5800
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Fax | 586-532-6496
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Provider Business Mailing Address
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Address Line | 45640 SCHOENHERR RD
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City | SHELBY TOWNSHIP
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State | MI
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Zip | 48315-6033
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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 | CEO/MANAGING EMPLOYEE (W2)
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Name | DR. CHRISTOPHER ROBERT PROVENZANO
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Credential | MD
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Telephone | 586-286-7800
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2086S0129X
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Taxonomy Name | Vascular Surgery Physician
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License Number |
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License Number State |
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Taxonomy #2
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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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