Provider Demographics
NPI:1831190701
Name:MACOMB FAMILY SERVICES, INC.
Entity type:Organization
Organization Name:MACOMB FAMILY SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:OWEN
Authorized Official - Middle Name:
Authorized Official - Last Name:PFAENDTNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-336-0422
Mailing Address - Street 1:36975 UTICA RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48036-1685
Mailing Address - Country:US
Mailing Address - Phone:586-226-3440
Mailing Address - Fax:586-226-3672
Practice Address - Street 1:36975 UTICA RD
Practice Address - Street 2:SUITE 103
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48036-1685
Practice Address - Country:US
Practice Address - Phone:586-226-3440
Practice Address - Fax:586-226-3740
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-02
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI251C00000X
MIN/A103TC0700X, 2084P0800X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No251C00000XAgenciesDay Training, Developmentally Disabled ServicesGroup - Single Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI125267OtherVALUE OPTIONS PIN # - ALL
MI20389OtherBLUE CROSS S/A
MI2066282OtherROMEO CIGNA PIN #
MI2068754OtherRICHMOND CIGNA PIN #
MI750910529OtherROMEO BLUE CROSS PIN #
MI750910671OtherSHELBY BLUE CROSS PIN #
MI20531OtherBLUE CROSS S/A
MI3396315Medicaid
MI13305OtherCLINTON CIGNA PIN #
MI750910710OtherBLUE CROSS BLUE SHIELD
MI20528OtherBLUE CROSS S/A
MI750910612OtherCLINTON BLUE CROSS PIN #
MIM07925OtherHAP PIN #- ALL SITES
MI20572OtherBLUE CROSS S/A
MI750910526OtherRICHMOND BLUE CROSS PIN #
MI77353OtherSHELBY CIGNA PIN #
MI750910529OtherROMEO BLUE CROSS PIN #
MI750910671OtherSHELBY BLUE CROSS PIN #