Basic Information
| Provider Information | |||||||||
| NPI: | 1134133895 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OAKWOOD HEALTHCARE, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | BEAUMONT HOSPITAL - TRENTON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 26901 BEAUMONT BLVD. | ||||||||
| Address2: | COMPLIANCE | ||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480334716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9475221963 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5450 FORT ST | ||||||||
| Address2: | |||||||||
| City: | TRENTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481834601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346713800 | ||||||||
| FaxNumber: | 7346713891 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2006 | ||||||||
| LastUpdateDate: | 07/11/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ODOM | ||||||||
| AuthorizedOfficialFirstName: | LEE | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT SHARED SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 9475223338 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | OAKWOOD HEALTCARE, INC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 820170 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 115178772 | 05 | MI | MEDICAID | 000000001929 | 01 | MI | CAPE HEALTH PROFESSIONAL | OTHER | OP821201 | 01 | MI | M-CARE PROFESSIONAL | OTHER | 0Q24603 | 01 | MI | BSHIELD/BCN PROFESSIONAL | OTHER |