Basic Information
| Provider Information | |||||||||
| NPI: | 1649943358 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HENRY FORD HEALTH SYSTEM | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HENRY FORD MEDICAL CENTER - ROYAL OAK | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 E 2ND ST | ||||||||
| Address2: | |||||||||
| City: | ROYAL OAK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480672694 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485462110 | ||||||||
| FaxNumber: | 3138761305 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 E 2ND ST | ||||||||
| Address2: | |||||||||
| City: | ROYAL OAK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480672694 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485462110 | ||||||||
| FaxNumber: | 3138761305 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2021 | ||||||||
| LastUpdateDate: | 08/19/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CEBALT | ||||||||
| AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | LEAD ENROLLMENT SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 3138746764 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology | 207X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 208800000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology | 261QA1903X | N | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 208600000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.