Provider Demographics
NPI:1063719292
Name:ST CLAIR SPECIALTY PHYSICIANS
Entity type:Organization
Organization Name:ST CLAIR SPECIALTY PHYSICIANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:PROVENZANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-886-8787
Mailing Address - Street 1:45640 SCHOENHERR ROAD
Mailing Address - Street 2:
Mailing Address - City:SHELBY TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48315
Mailing Address - Country:US
Mailing Address - Phone:586-247-4300
Mailing Address - Fax:586-532-6496
Practice Address - Street 1:5610 GAGE STREET
Practice Address - Street 2:SUITE A
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706
Practice Address - Country:US
Practice Address - Phone:208-367-3370
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-24
Last Update Date:2011-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty