Basic Information
| Provider Information | |||||||||
| NPI: | 1295767630 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HENRY FORD MAPLEGROVE CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HENRY FORD HEALTHSYSTEM | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6773 W MAPLE RD | ||||||||
| Address2: | |||||||||
| City: | WEST BLOOMFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483223013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486616100 | ||||||||
| FaxNumber: | 2486617347 | ||||||||
| Practice Location | |||||||||
| Address1: | 6773 W MAPLE RD | ||||||||
| Address2: | |||||||||
| City: | WEST BLOOMFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483223013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486616100 | ||||||||
| FaxNumber: | 2486617347 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CONNELLY | ||||||||
| AuthorizedOfficialFirstName: | JIM | ||||||||
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| AuthorizedOfficialTitleorPosition: | SR. VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3138748714 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | MI | X | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | 3245S0500X | MI | X | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | Substance Abuse Treatment, Children |
No ID Information.