Basic Information
| Provider Information | |||||||||
| NPI: | 1093943615 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROVIDENCE HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11692 BEAVERLAND | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482391357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3136225004 | ||||||||
| FaxNumber: | 2488495389 | ||||||||
| Practice Location | |||||||||
| Address1: | 22250 PROVIDENCE DR | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480754825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488493447 | ||||||||
| FaxNumber: | 2488495389 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2009 | ||||||||
| LastUpdateDate: | 06/23/2009 | ||||||||
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| AuthorizedOfficialLastName: | PALM | ||||||||
| AuthorizedOfficialFirstName: | KAI | ||||||||
| AuthorizedOfficialMiddleName: | KINYELL | ||||||||
| AuthorizedOfficialTitleorPosition: | RESIDENT PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 3136225004 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 4301094326 | MI | N | Ambulatory Health Care Facilities | Clinic/Center | 261QP2300X | 4301094326 | MI | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 282N00000X | 4301094326 | MI | Y | Hospitals | General Acute Care Hospital |
No ID Information.