Basic Information
| Provider Information | |||||||||
| NPI: | 1548617459 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GENESEE HEALTH SYSTEM | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WATER WAIVER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 725 MASON ST | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485032421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8102573736 | ||||||||
| FaxNumber: | 8102573785 | ||||||||
| Practice Location | |||||||||
| Address1: | 420 W 5TH AVE | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485032445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8102573740 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2016 | ||||||||
| LastUpdateDate: | 02/15/2019 | ||||||||
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| AuthorizedOfficialLastName: | TROOP | ||||||||
| AuthorizedOfficialFirstName: | JEAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | REIMBURSEMENT OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8104965543 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.