Basic Information
Provider Information | |||||||||
NPI: | 1386192417 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WILLIAM BEAUMONT HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BEAUMONT HOME MEDICAL EQUIPMENT | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 26901 BEAUMONT BLVD | ||||||||
Address2: | COMPLAINCE | ||||||||
City: | SOUTHFIELD | ||||||||
State: | MI | ||||||||
PostalCode: | 480333849 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9475221964 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 18181 OAKWOOD BLVD | ||||||||
Address2: | #104 | ||||||||
City: | DEARBORN | ||||||||
State: | MI | ||||||||
PostalCode: | 481245032 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2487439100 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/19/2016 | ||||||||
LastUpdateDate: | 10/01/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ODOM | ||||||||
AuthorizedOfficialFirstName: | LEE | ||||||||
AuthorizedOfficialMiddleName: | ANN | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT SHARED SERVICES | ||||||||
AuthorizedOfficialTelephone: | 9475223326 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/01/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | 5306004600 | MI | Y |   | Suppliers | Durable Medical Equipment & Medical Supplies |   |
No ID Information.