Provider Demographics
NPI:1942300884
Name:SOUTHEASTERN MICHIGAN MEDICAL CONSULTANTS PC
Entity Type:Organization
Organization Name:SOUTHEASTERN MICHIGAN MEDICAL CONSULTANTS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:RUDY
Authorized Official - Middle Name:JEROME
Authorized Official - Last Name:VERVAEKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-775-7400
Mailing Address - Street 1:21420 HARPER AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-3607
Mailing Address - Country:US
Mailing Address - Phone:586-775-7400
Mailing Address - Fax:586-775-0091
Practice Address - Street 1:21420 HARPER AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-3607
Practice Address - Country:US
Practice Address - Phone:586-775-7400
Practice Address - Fax:586-775-0091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301044898207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4329604OtherAETNA
MI010E023690OtherBCBS
MIB47051OtherHAP
MIDE9629OtherRAILROAD MEDICARE GROUP
MI010E023690OtherBCN
MI1942300884Medicaid
MIB47051Medicare UPIN
MI1942300884Medicaid
MI1105018171OtherBCN
MI0P26650Medicare PIN