Basic Information
| Provider Information | |||||||||
| NPI: | 1922275312 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST. CLAIR CARDIOVASCULAR SURGEONS, PLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25599 KELLY RD | ||||||||
| Address2: | SUITE A. | ||||||||
| City: | ROSEVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480664975 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867726000 | ||||||||
| FaxNumber: | 5867727700 | ||||||||
| Practice Location | |||||||||
| Address1: | 1117 STONE ST | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | PORT HURON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480603525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8109873558 | ||||||||
| FaxNumber: | 8109877557 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2008 | ||||||||
| LastUpdateDate: | 05/14/2008 | ||||||||
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| AuthorizedOfficialLastName: | LEES | ||||||||
| AuthorizedOfficialFirstName: | C. DOUGLAS | ||||||||
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| AuthorizedOfficialTitleorPosition: | TRUSTEE | ||||||||
| AuthorizedOfficialTelephone: | 5867726000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | 4301047134 | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
No ID Information.