Basic Information
| Provider Information | |||||||||
| NPI: | 1063719292 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST CLAIR SPECIALTY PHYSICIANS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 45640 SCHOENHERR ROAD | ||||||||
| Address2: | |||||||||
| City: | SHELBY TWP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5862474300 | ||||||||
| FaxNumber: | 5865326496 | ||||||||
| Practice Location | |||||||||
| Address1: | 5610 GAGE STREET | ||||||||
| Address2: | SUITE A | ||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083673370 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2011 | ||||||||
| LastUpdateDate: | 02/24/2011 | ||||||||
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| AuthorizedOfficialLastName: | PROVENZANO | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT/PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 3138868787 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
No ID Information.