Basic Information
| Provider Information | |||||||||
| NPI: | 1154361616 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST CLAIR SPECIALTY PHYSICIANS PC | ||||||||
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| OtherOrganizationName: | ST. CLAIR NEPHROLOGY, IDAHO NEPHROLOGY ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 45640 SCHOENHERR RD | ||||||||
| Address2: | |||||||||
| City: | SHELBY TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483156033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5862474300 | ||||||||
| FaxNumber: | 5865326496 | ||||||||
| Practice Location | |||||||||
| Address1: | 18001 E 10 MILE RD | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | ROSEVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480663803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5862185800 | ||||||||
| FaxNumber: | 5865326496 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 10/17/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | PROVENZANO | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
| AuthorizedOfficialMiddleName: | ROBERT | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO/MANAGING EMPLOYEE (W2) | ||||||||
| AuthorizedOfficialTelephone: | 5862867800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 10/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 207RN0300X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
No ID Information.