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General NPI Number Information
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NPI Number | 1962645689
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Entity Type | Organization
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Legal Business Name | HOME CLINIC PC
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Dates
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Enumeration Date | 04/10/2009
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Last Update Date | 09/24/2010
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Provider Practice Location Address
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Address Line | 23999 NORTHWESTERN HWY SUITE 110
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City | SOUTHFIELD
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State | MI
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Zip | 48075-2578
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Country | US
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Telephone | 248-909-9494
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Fax |
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Provider Business Mailing Address
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Address Line | 23999 NORTHWESTERN HWY SUITE 110
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City | SOUTHFIELD
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State | MI
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Zip | 48075-2578
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Country | US
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Telephone | 248-909-9494
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | PAUL PETRE
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Credential | MD
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Telephone | 248-909-9494
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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