Provider Demographics
NPI:1477621050
Name:EVERINGHAM CLINIC PC
Entity Type:Organization
Organization Name:EVERINGHAM CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:J
Authorized Official - Last Name:EVERINGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:734-941-1070
Mailing Address - Street 1:12100 HURON RIVER DRIVE
Mailing Address - Street 2:
Mailing Address - City:ROMULUS
Mailing Address - State:MI
Mailing Address - Zip Code:48174-1119
Mailing Address - Country:US
Mailing Address - Phone:734-941-1070
Mailing Address - Fax:734-941-1763
Practice Address - Street 1:12100 HURON RIVER DRIVE
Practice Address - Street 2:
Practice Address - City:ROMULUS
Practice Address - State:MI
Practice Address - Zip Code:48174-1119
Practice Address - Country:US
Practice Address - Phone:734-941-1070
Practice Address - Fax:734-941-1763
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOP41160Medicare UPIN