Basic Information
| Provider Information | |||||||||
| NPI: | 1164614798 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MCLAREN MEDICAL GROUP | ||||||||
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| OtherOrganizationName: | MCLAREN MEDICAL MANAGEMENT, INC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 S BALLENGER HWY | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485323638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8103421000 | ||||||||
| FaxNumber: | 8103421590 | ||||||||
| Practice Location | |||||||||
| Address1: | 2420 OWEN RD | ||||||||
| Address2: | |||||||||
| City: | FENTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484303417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8104962400 | ||||||||
| FaxNumber: | 8106290918 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2007 | ||||||||
| LastUpdateDate: | 04/04/2016 | ||||||||
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| AuthorizedOfficialLastName: | HARDIMON | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8103421040 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MCLAREN MEDICAL MANAGEMENT | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 700B511870 | 01 | MI | BLUE CARE NETWORK | OTHER |