Basic Information
Provider Information | |||||||||
NPI: | 1629146360 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ZYLAK | ||||||||
FirstName: | CARL | ||||||||
MiddleName: | J. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | HENRY FORD HEALTH SYSTEM | ||||||||
Address2: | 2799 WEST GRAND BOULEVARD | ||||||||
City: | DETROIT | ||||||||
State: | MI | ||||||||
PostalCode: | 48202 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3139169106 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | HENRY FORD HEALTH SYSTEM | ||||||||
Address2: | 2799 WEST GRAND BOULEVARD | ||||||||
City: | DETROIT | ||||||||
State: | MI | ||||||||
PostalCode: | 48202 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3139169106 | ||||||||
FaxNumber: | 3139161249 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/01/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 4301037426 | MI | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | CZ037426 | 01 |   | COMMERCIAL-COMMERCIAL NUMBER | OTHER | CZ037426 | 01 |   | CHAMPUS-CHAMPUS | OTHER |