Provider Demographics
NPI:1508864620
Name:ST CLAIR ADULT MEDICINE SPECIALISTS PC
Entity Type:Organization
Organization Name:ST CLAIR ADULT MEDICINE SPECIALISTS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:BETH
Authorized Official - Last Name:HARDWICKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-778-4080
Mailing Address - Street 1:PO BOX 673215
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48267-3215
Mailing Address - Country:US
Mailing Address - Phone:586-778-4080
Mailing Address - Fax:586-778-6055
Practice Address - Street 1:23411 JEFFERSON AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-1949
Practice Address - Country:US
Practice Address - Phone:586-778-4080
Practice Address - Fax:586-778-6055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-12
Last Update Date:2010-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMH404922207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4240936Medicaid
MI3389123Medicaid
MI110E010920OtherBCBS BCN
MI3384323Medicaid
MI4613977Medicaid
MI4989630Medicaid
MI4613977Medicaid