Basic Information
| Provider Information | |||||||||
| NPI: | 1679902597 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HENRY FORD WYANDOTTE HOSPITAL | ||||||||
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| OtherOrganizationName: | HFW CENTER FOR WEIGHT MANAGEMENT | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3333 BIDDLE AVE | ||||||||
| Address2: | |||||||||
| City: | WYANDOTTE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481926284 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342259112 | ||||||||
| FaxNumber: | 7342259176 | ||||||||
| Practice Location | |||||||||
| Address1: | 1640 FORT STREET | ||||||||
| Address2: | SUITE D ATTN DENISE | ||||||||
| City: | TRENTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7343913057 | ||||||||
| FaxNumber: | 7343913052 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2013 | ||||||||
| LastUpdateDate: | 11/18/2016 | ||||||||
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| AuthorizedOfficialLastName: | BUDD | ||||||||
| AuthorizedOfficialFirstName: | JACOB | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7343913057 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered | 207QB0002X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Bariatric Medicine | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.