Provider Demographics
NPI:1982756433
Name:UROLOGIC CLINIC OF SOUTHEASTERN MICHIGAN PLC
Entity type:Organization
Organization Name:UROLOGIC CLINIC OF SOUTHEASTERN MICHIGAN PLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:FREDERCIK
Authorized Official - Last Name:HARB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:734-462-5858
Mailing Address - Street 1:39000 7 MILE RD STE 2500
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-1006
Mailing Address - Country:US
Mailing Address - Phone:734-462-5858
Mailing Address - Fax:734-462-5860
Practice Address - Street 1:39000 7 MILE RD STE 2500
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-1006
Practice Address - Country:US
Practice Address - Phone:734-462-5858
Practice Address - Fax:734-462-5860
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2025-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301061957208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0827697OtherBLUE CROSS
MI126793OtherCARE CHOICES
MI340H249310OtherBLUE CROSS BLUE SHIELD MI
MI17069OtherM CARE
MI4105806Medicaid
MI0827697OtherBLUE CARE NETWORK
IL340016693OtherGBA RAILROAD MEDICARE
MI126793OtherPREFERRED CHOICES
MI5211703OtherAETNA
MI126793OtherCARE CHOICES
MI0827697OtherBLUE CROSS