Basic Information
| Provider Information | |||||||||
| NPI: | 1265665160 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHILDREN'S HOSPITAL OF MICHIGAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3901 BEAUBIEN ST | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482012119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3137455515 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3901 BEAUBIEN ST | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482012119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3137455515 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2009 | ||||||||
| LastUpdateDate: | 08/26/2009 | ||||||||
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| AuthorizedOfficialLastName: | LANCELOT | ||||||||
| AuthorizedOfficialFirstName: | MOIRA | ||||||||
| AuthorizedOfficialMiddleName: | MICHELLE | ||||||||
| AuthorizedOfficialTitleorPosition: | FELLOW | ||||||||
| AuthorizedOfficialTelephone: | 3137455515 | ||||||||
| 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 | 333600000X | 4301093680 | MI | Y | Suppliers | Pharmacy |
No ID Information.