Provider Demographics
NPI:1699949610
Name:FENTON CLINIC
Entity type:Organization
Organization Name:FENTON CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:LAVERN
Authorized Official - Last Name:TROLLMAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:DO
Authorized Official - Phone:810-629-4187
Mailing Address - Street 1:201 E CAROLINE ST
Mailing Address - Street 2:129
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-2105
Mailing Address - Country:US
Mailing Address - Phone:810-629-4187
Mailing Address - Fax:810-629-9662
Practice Address - Street 1:201 E CAROLINE ST
Practice Address - Street 2:129
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-2105
Practice Address - Country:US
Practice Address - Phone:810-629-4187
Practice Address - Fax:810-629-9662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-22
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010055954261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0152524585OtherMR BC PPOM
MI1001880Medicaid
MI1001880Medicaid
MI5252458Medicare PIN