Basic Information
| Provider Information | |||||||||
| NPI: | 1346407988 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROVIDENCE HOSPITAL | ||||||||
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| OtherOrganizationName: | PH CLINIC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16001 W 9 MILE RD | ||||||||
| Address2: | |||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480754818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488493000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 25925 TELEGRAPH RD | ||||||||
| Address2: | 210 | ||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480332518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2487463218 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2008 | ||||||||
| LastUpdateDate: | 05/21/2008 | ||||||||
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| AuthorizedOfficialLastName: | WHITMAN | ||||||||
| AuthorizedOfficialFirstName: | SANDRA | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR PHYSICIAN BILLING | ||||||||
| AuthorizedOfficialTelephone: | 2487463218 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0F31976 | 01 | MI | BCBSM | OTHER |