Basic Information
| Provider Information | |||||||||
| NPI: | 1275523060 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCCLOSKEY | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | W. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 43800 GARFIELD RD | ||||||||
| Address2: | |||||||||
| City: | CLINTON TWP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480381136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008480202 | ||||||||
| FaxNumber: | 5862266949 | ||||||||
| Practice Location | |||||||||
| Address1: | 27450 SCHOENHERR RD | ||||||||
| Address2: | 400 | ||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480886683 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5865827550 | ||||||||
| FaxNumber: | 5865827515 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2005 | ||||||||
| LastUpdateDate: | 02/07/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4301055273 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4142416 | 05 | MI | MEDICAID | 5182480 | 05 | MI | MEDICAID |