Basic Information
| Provider Information | |||||||||
| NPI: | 1508864620 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST CLAIR ADULT MEDICINE SPECIALISTS PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 673215 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482673215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867784080 | ||||||||
| FaxNumber: | 5867786055 | ||||||||
| Practice Location | |||||||||
| Address1: | 23411 JEFFERSON AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SAINT CLAIR SHORES | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480801949 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867784080 | ||||||||
| FaxNumber: | 5867786055 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2005 | ||||||||
| LastUpdateDate: | 07/16/2010 | ||||||||
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| AuthorizedOfficialLastName: | HARDWICKE | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | BETH | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 5867784080 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MH404922 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4240936 | 05 | MI | MEDICAID | 3389123 | 05 | MI | MEDICAID | 110E010920 | 01 | MI | BCBS BCN | OTHER | 3384323 | 05 | MI | MEDICAID | 4613977 | 05 | MI | MEDICAID | 4989630 | 05 | MI | MEDICAID |