Provider Demographics
NPI:1093756934
Name:PORT HURON CLINIC P.C.
Entity Type:Organization
Organization Name:PORT HURON CLINIC P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MORTIMER
Authorized Official - Middle Name:
Authorized Official - Last Name:LEVIN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:248-569-5100
Mailing Address - Street 1:PO BOX 198
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48037-0198
Mailing Address - Country:US
Mailing Address - Phone:248-569-5100
Mailing Address - Fax:248-569-4774
Practice Address - Street 1:1107 STONE ST
Practice Address - Street 2:STE #1
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3569
Practice Address - Country:US
Practice Address - Phone:810-982-8300
Practice Address - Fax:810-982-8308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI003615173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P25070Medicare ID - Type Unspecified