Basic Information
| Provider Information | |||||||||
| NPI: | 1609844976 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY CARE SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26184 W OUTER DRIVE | ||||||||
| Address2: | |||||||||
| City: | LINCOLN PARK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3133897525 | ||||||||
| FaxNumber: | 3133897515 | ||||||||
| Practice Location | |||||||||
| Address1: | 26184 W OUTER DRIVE | ||||||||
| Address2: | |||||||||
| City: | LINCOLN PARK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3133897525 | ||||||||
| FaxNumber: | 3133897515 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | WALSH | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3133897525 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | LMSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC1500X | X | Ambulatory Health Care Facilities | Clinic/Center | Community Health | 261QR0405X | 820588 | MI | X | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 261QR0405X | 820521 | MI | X | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 261QR0405X | 820428 | MI | X | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
ID Information
| ID | Type | State | Issuer | Description | 6842 | 01 | MIDWEST HEALTH PLAN | OTHER | 040397 | 01 | VALUE OPTIONS | OTHER | 20710 | 01 | BCBS | OTHER | 6322 | 01 | CAPE HEALTH PLAN | OTHER | 6U4765 | 01 | HEALTH ALLIANCE PLAN | OTHER | P42560 | 01 | BLUE CARE NETWORK | OTHER | 20709 | 01 | BCBS | OTHER | 207711 | 01 | BCBS | OTHER | 3119549 | 05 | MI | MEDICAID |