Basic Information
Provider Information
NPI: 1083959480
EntityType: 2
ReplacementNPI:  
OrganizationName: HENRY FORD WYANDOTTE HOSPITAL
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 2333 BIDDLE AVE
Address2:  
City: WYANDOTTE
State: MI
PostalCode: 481924668
CountryCode: US
TelephoneNumber: 7342469827
FaxNumber: 7342467937
Practice Location
Address1: 2333 BIDDLE AVE
Address2:  
City: WYANDOTTE
State: MI
PostalCode: 481924668
CountryCode: US
TelephoneNumber: 7342469827
FaxNumber: 7342467937
Other Information
ProviderEnumerationDate: 12/11/2012
LastUpdateDate: 12/11/2012
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: DUBOSH
AuthorizedOfficialFirstName: JOHN
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: MANAGER
AuthorizedOfficialTelephone: 7343243535
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: MR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: MA, LLP, LMSW
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
282NC0060X  Y HospitalsGeneral Acute Care HospitalCritical Access

No ID Information.


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