Basic Information
| Provider Information | |||||||||
| NPI: | 1619125788 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OAKLAND PHYSICIANS MEDICAL CENTER, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PONTIAC GENERAL HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 461 WEST HURON STREET | ||||||||
| Address2: | |||||||||
| City: | PONTIAC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488577200 | ||||||||
| FaxNumber: | 2488576842 | ||||||||
| Practice Location | |||||||||
| Address1: | 461 WEST HURON STREET | ||||||||
| Address2: | |||||||||
| City: | PONTIAC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488577200 | ||||||||
| FaxNumber: | 2488576842 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/03/2008 | ||||||||
| LastUpdateDate: | 09/08/2017 | ||||||||
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| AuthorizedOfficialLastName: | JODWAY | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2488577200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | MI | N | Ambulatory Health Care Facilities | Clinic/Center | Radiology | 261QU0200X | MI | N | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 5435510 | 05 | MI | MEDICAID |