Provider Demographics
NPI:1821000670
Name:CLIVE, PETER J (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:J
Last Name:CLIVE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:2815 BARDAMAR DR
Mailing Address - Street 2:
Mailing Address - City:FORT GRATIOT
Mailing Address - State:MI
Mailing Address - Zip Code:48059-3505
Mailing Address - Country:US
Mailing Address - Phone:810-385-9621
Mailing Address - Fax:810-385-0933
Practice Address - Street 1:2770 MAIN ST
Practice Address - Street 2:
Practice Address - City:MARLETTE
Practice Address - State:MI
Practice Address - Zip Code:48453-1141
Practice Address - Country:US
Practice Address - Phone:989-635-1833
Practice Address - Fax:810-385-0933
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI0673012085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3284434Medicaid
MI3284434Medicaid
MIP61380001Medicare UPIN
MIP61380001Medicare UPIN