Provider Demographics
NPI:1669837993
Name:ST. CHARLES FAMILY CLINIC PLLC
Entity Type:Organization
Organization Name:ST. CHARLES FAMILY CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NAVEED
Authorized Official - Middle Name:
Authorized Official - Last Name:MAHFOOZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:989-865-9958
Mailing Address - Street 1:611 W BELLE AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MI
Mailing Address - Zip Code:48655-1611
Mailing Address - Country:US
Mailing Address - Phone:989-865-9958
Mailing Address - Fax:989-865-8099
Practice Address - Street 1:611 W BELLE AVENUE
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MI
Practice Address - Zip Code:48655
Practice Address - Country:US
Practice Address - Phone:989-865-9958
Practice Address - Fax:989-865-8099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-31
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301059644207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty