Provider Demographics
NPI:1366436511
Name:SOUTH MACOMB INTERNISTS, P.C.
Entity type:Organization
Organization Name:SOUTH MACOMB INTERNISTS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:BARON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-751-2072
Mailing Address - Street 1:11900 E 12 MILE RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-3400
Mailing Address - Country:US
Mailing Address - Phone:586-761-2072
Mailing Address - Fax:586-751-1302
Practice Address - Street 1:11900 E 12 MILE RD
Practice Address - Street 2:SUITE 300
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-3400
Practice Address - Country:US
Practice Address - Phone:586-761-2072
Practice Address - Fax:586-751-1302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-02
Last Update Date:2007-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700E06357OtherBCBSM
MI700E06357OtherBCBSM