Provider Demographics
NPI:1083669691
Name:MCLAREN MACOMB
Entity Type:Organization
Organization Name:MCLAREN MACOMB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:M
Authorized Official - Last Name:BRISSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-493-8083
Mailing Address - Street 1:1000 HARRINGTON BLVD.
Mailing Address - Street 2:ATTN: SPECIAL CARE NURSERY
Mailing Address - City:MT. CLEMENS
Mailing Address - State:MI
Mailing Address - Zip Code:48043-2920
Mailing Address - Country:US
Mailing Address - Phone:586-493-8296
Mailing Address - Fax:586-741-4114
Practice Address - Street 1:1000 HARRINGTON BLVD.
Practice Address - Street 2:ATTN: SPECIAL CARE NURSERY
Practice Address - City:MT. CLEMENS
Practice Address - State:MI
Practice Address - Zip Code:48043
Practice Address - Country:US
Practice Address - Phone:586-493-8296
Practice Address - Fax:586-741-4114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301085002208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4819971Medicaid
MI4819971Medicaid