Basic Information
Provider Information | |||||||||
NPI: | 1518159722 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | THE DETROIT OSTEOPATHIC HOSPITAL CORPORATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BI-COUNTY CLINICAL PRACTICES | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 13251 E 10 MILE RD | ||||||||
Address2: | STE 300 | ||||||||
City: | WARREN | ||||||||
State: | MI | ||||||||
PostalCode: | 480892076 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5867586263 | ||||||||
FaxNumber: | 5867587725 | ||||||||
Practice Location | |||||||||
Address1: | 13251 E 10 MILE RD | ||||||||
Address2: | STE 300 | ||||||||
City: | WARREN | ||||||||
State: | MI | ||||||||
PostalCode: | 480892076 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5867586263 | ||||||||
FaxNumber: | 5867587725 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/11/2007 | ||||||||
LastUpdateDate: | 08/11/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KIBBLE | ||||||||
AuthorizedOfficialFirstName: | JOHN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 3138743436 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | THE DETROIT OSTEOPATHIC HOSPITAL CORPORATION | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   |
No ID Information.