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NPI Code Detail

MEDICARE: SHENANDOAH CLINIC, P.C.

MEDICARE: SHENANDOAH CLINIC, P.C.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207Q00000XFamily Medicine Physician

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1080F319020OTHERMIBLUE CROSS BLUE SHIELD

General Provider Information

NPI Number : 1043394877
Entity Type Code : Organization
Provider Name (Legal Business Name) : SHENANDOAH CLINIC, P.C.
Provider Business Mailing Address
First Line : 909 W MAPLE RD
Second Line : SUITE 100
City : CLAWSON
State : MI
Zip : 48017-1000
Country : US
Telephone Number : 248-435-2028
Fax Number : 248-435-2099
Provider Business Practice Location Address
First Line : 909 W MAPLE RD
Second Line : SUITE 100
City : CLAWSON
State : MI
Zip : 48017-1000
Country : US
Telephone Number : 248-435-2028
Fax Number : 248-435-2099
Authorized Official
Title or Position : PHYSICIAN/PRESIDENT
Name : DR. RONALD I ROTHENBERG
Credential : DO
Telephone Number : 248-435-2028
Provider Enumeration Date : 10/25/2006
Last Update Date : 02/24/2022

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