Basic Information
| Provider Information | |||||||||
| NPI: | 1699969782 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DETROIT MACOMB-OAKLAND HOSPITAL CORPORATION | ||||||||
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| OtherOrganizationName: | MACOMB HOSPITAL ACADEMIC MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25925 TELEGRAPH RD | ||||||||
| Address2: | 210 | ||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480332518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2487463218 | ||||||||
| FaxNumber: | 2487460369 | ||||||||
| Practice Location | |||||||||
| Address1: | 11885 E 12 MILE RD | ||||||||
| Address2: | 300A | ||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480933474 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5865826630 | ||||||||
| FaxNumber: | 5865826631 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2007 | ||||||||
| LastUpdateDate: | 08/31/2007 | ||||||||
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| AuthorizedOfficialLastName: | WHITMAN | ||||||||
| AuthorizedOfficialFirstName: | SANDRA | ||||||||
| AuthorizedOfficialMiddleName: | ELLEN | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2487465822 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DETROIT MACOMB-OAKLAND HOSPITAL CORPORATION | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.