Provider Demographics
NPI:1174665988
Name:POLYCLINIC ASSOCIATES PC
Entity Type:Organization
Organization Name:POLYCLINIC ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGR
Authorized Official - Prefix:
Authorized Official - First Name:TOM
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUSSEAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-663-9846
Mailing Address - Street 1:26400 W 12 MILE RD
Mailing Address - Street 2:STE 38
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-1700
Mailing Address - Country:US
Mailing Address - Phone:248-663-9846
Mailing Address - Fax:248-663-9854
Practice Address - Street 1:26400 W 12 MILE RD
Practice Address - Street 2:STE 38
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1700
Practice Address - Country:US
Practice Address - Phone:248-663-9846
Practice Address - Fax:248-663-9854
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
MI50011601213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Not Answered213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0F36449Medicare ID - Type UnspecifiedGROUP NUMBER