Basic Information
| Provider Information | |||||||||
| NPI: | 1538256789 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MACOMB NEPHROLOGY ASSOCIATES P.L.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15520 19 MILE RD | ||||||||
| Address2: | SUITE 480 | ||||||||
| City: | CLINTON TWP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480386333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5862281010 | ||||||||
| FaxNumber: | 5862288570 | ||||||||
| Practice Location | |||||||||
| Address1: | 15520 19 MILE RD | ||||||||
| Address2: | SUITE 480 | ||||||||
| City: | CLINTON TWP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480386333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5862281010 | ||||||||
| FaxNumber: | 5862288570 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2006 | ||||||||
| LastUpdateDate: | 04/18/2022 | ||||||||
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| AuthorizedOfficialLastName: | GUNST | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5862281010 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 110E01220 | 01 | MI | BLUE CROSS BLUE SHIELD MI | OTHER |