Provider Demographics
NPI:1043394877
Name:SHENANDOAH CLINIC, P.C.
Entity Type:Organization
Organization Name:SHENANDOAH CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:I
Authorized Official - Last Name:ROTHENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:248-435-2028
Mailing Address - Street 1:909 W MAPLE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CLAWSON
Mailing Address - State:MI
Mailing Address - Zip Code:48017-1000
Mailing Address - Country:US
Mailing Address - Phone:248-435-2028
Mailing Address - Fax:248-435-2099
Practice Address - Street 1:909 W MAPLE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:CLAWSON
Practice Address - State:MI
Practice Address - Zip Code:48017-1000
Practice Address - Country:US
Practice Address - Phone:248-435-2028
Practice Address - Fax:248-435-2099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI080F319020OtherBLUE CROSS BLUE SHIELD