Basic Information
| Provider Information | |||||||||
| NPI: | 1215057609 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MCLAREN MACOMB | ||||||||
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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: | 36500 S GRATIOT AVE | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | CLINTON TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867909003 | ||||||||
| FaxNumber: | 5864933603 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2007 | ||||||||
| LastUpdateDate: | 05/23/2018 | ||||||||
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| AuthorizedOfficialLastName: | BRISSE | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5864938083 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 110E062060 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER |