Provider Demographics
NPI:1710202825
Name:HOME CLINIC PC
Entity Type:Organization
Organization Name:HOME CLINIC PC
Other - Org Name:GREAT LAKES PHYSICIANS OF SOUTHFIELD, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:PETRE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-223-1500
Mailing Address - Street 1:2980 N BEVERLY GLEN CIR
Mailing Address - Street 2:STE 301
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90077-1726
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:23999 NORTHWESTERN HWY
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-2578
Practice Address - Country:US
Practice Address - Phone:248-223-1500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HOME CLINIC PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-03-31
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1676OtherPTAN