Basic Information
| Provider Information | |||||||||
| NPI: | 1932292166 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CLARKSTON MEDICAL GROUP PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5701 BOW POINTE DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CLARKSTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483463198 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486252621 | ||||||||
| FaxNumber: | 2486258938 | ||||||||
| Practice Location | |||||||||
| Address1: | 5701 BOW POINTE DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CLARKSTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483463198 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486252621 | ||||||||
| FaxNumber: | 2486258938 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 12/02/2010 | ||||||||
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| AuthorizedOfficialLastName: | O'NEILL | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2486252621 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4301023587 | MI | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 208000000X | 4301023587 | MI | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | 4301023587 | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 700F313410 | 01 | MI | BCBS GROUP | OTHER | 1932292166 | 05 | MI | MEDICAID | 700F313410 | 01 | MI | BCN GROUP | OTHER |