Basic Information
| Provider Information | |||||||||
| NPI: | 1770635773 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HENRY FORD SHAPED BEAM SURGERY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2799 W GRAND BLVD. #M216 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3139161078 | ||||||||
| FaxNumber: | 3139163235 | ||||||||
| Practice Location | |||||||||
| Address1: | 2799 W GRAND BLVD # M216 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482022608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3139161078 | ||||||||
| FaxNumber: | 3139163235 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | WINESKI | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3139161078 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
ID Information
| ID | Type | State | Issuer | Description | 0H21883 | 01 | MI | BLUE CROSS | OTHER | 514930 | 01 | MI | HAP | OTHER |