Basic Information
| Provider Information | |||||||||
| NPI: | 1053342220 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HAVENWYCK HOSPITAL INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1525 UNIVERSITY DR | ||||||||
| Address2: | |||||||||
| City: | AUBURN HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483262673 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483739200 | ||||||||
| FaxNumber: | 2483734113 | ||||||||
| Practice Location | |||||||||
| Address1: | 1525 UNIVERSITY DR | ||||||||
| Address2: | |||||||||
| City: | AUBURN HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483262673 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483739200 | ||||||||
| FaxNumber: | 2483734113 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 03/17/2011 | ||||||||
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| AuthorizedOfficialLastName: | FILTON | ||||||||
| AuthorizedOfficialFirstName: | STEVE | ||||||||
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| AuthorizedOfficialTitleorPosition: | SRVP CFO | ||||||||
| AuthorizedOfficialTelephone: | 6107683300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283Q00000X | H-075/2006 | MI | Y | Hospitals | Psychiatric Hospital |
ID Information
| ID | Type | State | Issuer | Description | 170528921 | 05 | MI | MEDICAID | 00106 | 01 | MI | BLUE CROSS BLUE SHIELD OF MICHIGAN | OTHER |