Provider Demographics
NPI:1922275312
Name:ST. CLAIR CARDIOVASCULAR SURGEONS, PLC
Entity Type:Organization
Organization Name:ST. CLAIR CARDIOVASCULAR SURGEONS, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TRUSTEE
Authorized Official - Prefix:
Authorized Official - First Name:C. DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:LEES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-772-6000
Mailing Address - Street 1:25599 KELLY RD
Mailing Address - Street 2:SUITE A.
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-4975
Mailing Address - Country:US
Mailing Address - Phone:586-772-6000
Mailing Address - Fax:586-772-7700
Practice Address - Street 1:1117 STONE ST
Practice Address - Street 2:SUITE 1
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3525
Practice Address - Country:US
Practice Address - Phone:810-987-3558
Practice Address - Fax:810-987-7557
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-14
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301047134208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M392100Medicare PIN