Basic Information
| Provider Information | |||||||||
| NPI: | 1477550564 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OUTER DRIVE PARTNERS LLC | ||||||||
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| OtherOrganizationName: | HARTFORD NURSING & REHAB CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4000 TOWN CTR STE 700 | ||||||||
| Address2: | |||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480751424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483860300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6700 W OUTER DR | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482352724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138361700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2005 | ||||||||
| LastUpdateDate: | 11/16/2016 | ||||||||
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| AuthorizedOfficialLastName: | QAZI | ||||||||
| AuthorizedOfficialFirstName: | MOHAMMAD | ||||||||
| AuthorizedOfficialMiddleName: | ASHRAF | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2483860300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CIENA HEALTHCARE MANAGEMENT, INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 09999 | 01 | MI | BCBSM | OTHER | 4690715 | 05 | MI | MEDICAID |