Provider Demographics
NPI:1750327771
Name:CLARKSTON HEALTH CENTER
Entity Type:Organization
Organization Name:CLARKSTON HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLI
Authorized Official - Middle Name:K
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:RT
Authorized Official - Phone:248-620-4227
Mailing Address - Street 1:5625 WATER TOWER PL
Mailing Address - Street 2:SUITE G-33
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-2671
Mailing Address - Country:US
Mailing Address - Phone:248-620-4222
Mailing Address - Fax:248-620-4234
Practice Address - Street 1:5625 WATER TOWER PL
Practice Address - Street 2:SUITE G-33
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-2671
Practice Address - Country:US
Practice Address - Phone:248-620-4222
Practice Address - Fax:248-620-4234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7753052085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI000000009522OtherCAPE MEDICAL
MION75750OtherHAP
MI137850OtherCARE CHOICES
MIOF30168OtherBLUE CARE NETWORK
MIOF30168OtherBLUE CROSS BLUE SHIELD OF
MI0996948OtherHEALTH PLUS OF MI
MI137850OtherPREFERRED CHOICES
MI16442OtherM-CARE
MI7065650OtherCIGNA
MION75750OtherHAP
MIOF30168OtherBLUE CROSS BLUE SHIELD OF
MI7065650OtherCIGNA