Provider Demographics
NPI:1821049990
Name:MCLAREN MACOMB
Entity Type:Organization
Organization Name:MCLAREN MACOMB
Other - Org Name:PEDIATRIC SPECIALTY GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:M
Authorized Official - Last Name:BRISSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-493-8083
Mailing Address - Street 1:43900 GARFIELD RD
Mailing Address - Street 2:STE. 201
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1128
Mailing Address - Country:US
Mailing Address - Phone:586-412-5110
Mailing Address - Fax:586-412-5116
Practice Address - Street 1:43900 GARFIELD RD
Practice Address - Street 2:STE. 201
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038
Practice Address - Country:US
Practice Address - Phone:586-412-5110
Practice Address - Fax:586-412-5116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-13
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0008XAllopathic & Osteopathic PhysiciansPediatricsNeurodevelopmental DisabilitiesGroup - Multi-Specialty
No2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric CardiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4168314Medicaid
MI3518937Medicaid
MI3298780Medicaid
MI3298762Medicaid
MI4168314Medicaid
MI3518937Medicaid
MI3298780Medicaid
MIE38498Medicare UPIN