Basic Information
| Provider Information | |||||||||
| NPI: | 1043535990 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BI COUNTY CLINICAL PRACTICES | ||||||||
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| OtherOrganizationName: | HENRY FORD MACOMB HOSPITAL-WARREN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 673195 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482673195 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8107205715 | ||||||||
| FaxNumber: | 8107320891 | ||||||||
| Practice Location | |||||||||
| Address1: | 27500 HOOVER RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480934586 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867542558 | ||||||||
| FaxNumber: | 5867542426 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2010 | ||||||||
| LastUpdateDate: | 07/20/2010 | ||||||||
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| AuthorizedOfficialLastName: | GOODBALIAN | ||||||||
| AuthorizedOfficialFirstName: | TERRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5862632705 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 700E002070 | 01 | MI | BCBSM/BCN | OTHER |