Basic Information
| Provider Information | |||||||||
| NPI: | 1144634403 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HENRY FORD WYANDOTTE HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2333 BIDDLE AVE | ||||||||
| Address2: | |||||||||
| City: | WYANDOTTE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481924668 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342466000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1640 FORT STREET | ||||||||
| Address2: | SUITE D ATTN DENISE | ||||||||
| City: | TRENTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7343913057 | ||||||||
| FaxNumber: | 7343913052 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2014 | ||||||||
| LastUpdateDate: | 03/19/2021 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
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| AuthorizedOfficialTitleorPosition: | SVP | ||||||||
| AuthorizedOfficialTelephone: | 5172056407 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 03/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.