Provider Demographics
NPI:1730243262
Name:CHARLES R STERN PC INTERVISIONS
Entity type:Organization
Organization Name:CHARLES R STERN PC INTERVISIONS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:RAYMOND
Authorized Official - Last Name:STERN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:586-445-3612
Mailing Address - Street 1:1839 SHIPMAN
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009
Mailing Address - Country:US
Mailing Address - Phone:586-445-3612
Mailing Address - Fax:586-445-0700
Practice Address - Street 1:20811 KELLY
Practice Address - Street 2:
Practice Address - City:EASTPOINTE
Practice Address - State:MI
Practice Address - Zip Code:48021
Practice Address - Country:US
Practice Address - Phone:586-445-3612
Practice Address - Fax:586-445-0700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301005261103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0F34861Medicare PIN