Basic Information
| Provider Information | |||||||||
| NPI: | 1144210253 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ASCENSION PROVIDENCE HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25925 TELEGRAPH RD | ||||||||
| Address2: | STE 210 | ||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480342518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486808000 | ||||||||
| FaxNumber: | 2487460384 | ||||||||
| Practice Location | |||||||||
| Address1: | 47601 GRAND RIVER AVE | ||||||||
| Address2: | |||||||||
| City: | NOVI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483741233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2484654170 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2005 | ||||||||
| LastUpdateDate: | 03/31/2020 | ||||||||
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| AuthorizedOfficialLastName: | WIEMANN | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2488493010 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 03/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 100082 | 01 | CARE CHOICE | OTHER | 934000 | 01 | BEAUMONT | OTHER | 118635 | 01 | GREAT LAKES | OTHER | 00277 | 01 | BLUE CROSS | OTHER | 0061570 | 01 | AETNA | OTHER | M004776 | 01 | TRICARE | OTHER | 00000001504A | 01 | CAPE | OTHER | 1015800008 | 01 | BOTSFORD | OTHER | HL630006 | 01 | MCARE | OTHER |