Provider Demographics
NPI:1184723694
Name:CARL F. CLAVENNA, M.D., P.C.
Entity type:Organization
Organization Name:CARL F. CLAVENNA, M.D., P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:F
Authorized Official - Last Name:CLAVENNA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-646-3733
Mailing Address - Street 1:600 S ADAMS RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-6861
Mailing Address - Country:US
Mailing Address - Phone:248-646-3733
Mailing Address - Fax:248-642-2566
Practice Address - Street 1:600 S ADAMS RD
Practice Address - Street 2:SUITE 200
Practice Address - City:BIRMINGHAM
Practice Address - State:MI
Practice Address - Zip Code:48009-6861
Practice Address - Country:US
Practice Address - Phone:248-646-3733
Practice Address - Fax:248-642-2566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI332H00000X
207W00000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No332H00000XSuppliersEyewear SupplierGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI180F321870OtherBLUE CROSS GROUP
MIG5031FOtherBLUE CARE NETWORK GROUP
MI1238300001Medicare ID - Type UnspecifiedDURABLE MEDICAL EQUIP
MIF48420Medicare UPIN
H50483Medicare UPIN
MI180F321870OtherBLUE CROSS GROUP
MICN6461Medicare ID - Type UnspecifiedMEDICARE RAILROAD GROUP #