Provider Demographics
NPI:1073385738
Name:ST. CLAIR ORTHOPAEDICS AND SPORTS MEDICINE PC
Entity Type:Organization
Organization Name:ST. CLAIR ORTHOPAEDICS AND SPORTS MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:ELAINE
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSETTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-552-4573
Mailing Address - Street 1:23829 LITTLE MACK AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-1186
Mailing Address - Country:US
Mailing Address - Phone:586-773-1300
Mailing Address - Fax:
Practice Address - Street 1:23829 LITTLE MACK AVE STE 100
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-1186
Practice Address - Country:US
Practice Address - Phone:586-773-1300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-26
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHandGroup - Multi-Specialty