Basic Information
| Provider Information | |||||||||
| NPI: | 1356426290 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTH OAKLAND MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | NOMC PHYSICIAN SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8221 RELIABLE PKWY | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606860001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488577583 | ||||||||
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| Practice Location | |||||||||
| Address1: | 461 W HURON ST | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | PONTIAC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483411601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488577583 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2006 | ||||||||
| LastUpdateDate: | 11/26/2007 | ||||||||
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| AuthorizedOfficialLastName: | WILLBRANDT | ||||||||
| AuthorizedOfficialFirstName: | LESLEY | ||||||||
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| AuthorizedOfficialTitleorPosition: | SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 2488577595 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080N0001X | MI | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine | 208000000X | MI | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 363A00000X | MI | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 176B00000X | MI | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Midwife | 363L00000X | MI | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 103TC1900X | 6301012980 | MI | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Counseling | 208600000X | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.