Basic Information
| Provider Information | |||||||||
| NPI: | 1710992557 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WAYNE STATE UNIVERSITY SCHOOL OF MEDICINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4201 SAINT ANTOINE ST | ||||||||
| Address2: | UHC-8C | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482012153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3137451540 | ||||||||
| FaxNumber: | 3135774641 | ||||||||
| Practice Location | |||||||||
| Address1: | 4201 SAINT ANTOINE ST | ||||||||
| Address2: | UHC-8C | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482012153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3137451540 | ||||||||
| FaxNumber: | 3135774641 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | LI | ||||||||
| AuthorizedOfficialFirstName: | JUN | ||||||||
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| AuthorizedOfficialTitleorPosition: | ASSISTANT PROFESSOR | ||||||||
| AuthorizedOfficialTelephone: | 3137451540 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D.,PHD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 4301076212 | MI | Y | Hospitals | General Acute Care Hospital |
No ID Information.