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General NPI Number Information
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NPI Number | 1942300884
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Entity Type | Organization
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Legal Business Name | SOUTHEASTERN MICHIGAN MEDICAL CONSULTANTS PC
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Dates
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Enumeration Date | 09/22/2006
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Last Update Date | 02/06/2015
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Provider Practice Location Address
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Address Line | 21420 HARPER AVE SUITE 2
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City | SAINT CLAIR SHORES
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State | MI
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Zip | 48080-3607
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Country | US
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Telephone | 586-775-7400
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Fax | 586-775-0091
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Provider Business Mailing Address
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Address Line | 21420 HARPER AVE SUITE 2
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City | SAINT CLAIR SHORES
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State | MI
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Zip | 48080-3607
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Country | US
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Telephone | 586-775-7400
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Fax | 586-775-0091
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Authorized Official
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Title or Position | CEO
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Name | DR. RUDY JEROME VERVAEKE
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Credential | MD
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Telephone | 586-775-7400
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RA0401X
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Taxonomy Name | Addiction Medicine (Internal Medicine) Physician
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License Number | 4301044898
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License Number State | MI
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