Provider Demographics
NPI:1992033864
Name:NORTH CLINIC, P.C.
Entity Type:Organization
Organization Name:NORTH CLINIC, P.C.
Other - Org Name:PETER H. GAGGOS, D.O.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:H
Authorized Official - Last Name:GAGGOS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:313-532-5030
Mailing Address - Street 1:20041 WEST EIGHT MILE ROAD
Mailing Address - Street 2:NORTH CLINIC, P.C.
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48219
Mailing Address - Country:US
Mailing Address - Phone:313-532-5030
Mailing Address - Fax:313-532-0552
Practice Address - Street 1:20041 WEST EIGHT MILE ROAD
Practice Address - Street 2:NORTH CLINIC, P.C.
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48219
Practice Address - Country:US
Practice Address - Phone:313-532-5030
Practice Address - Fax:313-532-0552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-03
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1025621Medicaid
MIE24677Medicare UPIN
MI1025621Medicaid