Provider Demographics
NPI:1528587854
Name:ST. CLAIR ORTHOPAEDICS AND SPORTS MEDICINE PC
Entity Type:Organization
Organization Name:ST. CLAIR ORTHOPAEDICS AND SPORTS MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:KANWALDEEP
Authorized Official - Middle Name:
Authorized Official - Last Name:SIDHU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-552-4571
Mailing Address - Street 1:23829 LITTLE MACK AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-1186
Mailing Address - Country:US
Mailing Address - Phone:586-773-1300
Mailing Address - Fax:
Practice Address - Street 1:23829 LITTLE MACK AVE STE 100
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-1186
Practice Address - Country:US
Practice Address - Phone:586-773-1300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0E02122OtherBCBS PIN
MI0E05556OtherBCBS DME PIN