Provider Demographics
NPI:1356394571
Name:MCLAREN MACOMB
Entity type:Organization
Organization Name:MCLAREN MACOMB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
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 1:36500 S GRATIOT AVE
Mailing Address - Street 2:STE. 202
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-1772
Mailing Address - Country:US
Mailing Address - Phone:586-493-3727
Mailing Address - Fax:586-493-3720
Practice Address - Street 1:36500 S GRATIOT AVE
Practice Address - Street 2:STE. 202
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48035
Practice Address - Country:US
Practice Address - Phone:586-493-3727
Practice Address - Fax:586-493-3720
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101010690207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4468240Medicaid
MIF05083Medicare UPIN