Provider Demographics
NPI:1760708499
Name:CLARKSTON URGENT CARE PLC
Entity Type:Organization
Organization Name:CLARKSTON URGENT CARE PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:R
Authorized Official - Last Name:ONEILL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:248-625-2621
Mailing Address - Street 1:5701 BOW POINTE DR
Mailing Address - Street 2:SUITE 120
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-3198
Mailing Address - Country:US
Mailing Address - Phone:248-625-2273
Mailing Address - Fax:248-625-6336
Practice Address - Street 1:5701 BOW POINTE DR
Practice Address - Street 2:SUITE 120
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-3198
Practice Address - Country:US
Practice Address - Phone:248-625-2273
Practice Address - Fax:248-625-6336
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLARKSTON MEDICAL GROUP, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-04-20
Last Update Date:2011-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101011134207P00000X
MI5101009832207Q00000X
MI4301074879207R00000X
MI4301048260208000000X
MI51010111232083P0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI616157800OtherDEPT OF LABOR
MI1760708499Medicaid
MIDR1705OtherRAILROAD MEDICARE GROUP
MI700F392560OtherBCBS GROUP
MIDR1705OtherRAILROAD MEDICARE GROUP