Basic Information
| Provider Information | |||||||||
| NPI: | 1770869257 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DETROIT MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24131 PRINCETON ST | ||||||||
| Address2: | |||||||||
| City: | DEARBORN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481243264 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4201 SAINT ANTOINE ST STE 6A | ||||||||
| Address2: | DRH UNIVERSITY HEALTH CENTER | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482012153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3137454230 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2011 | ||||||||
| LastUpdateDate: | 10/27/2011 | ||||||||
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| AuthorizedOfficialLastName: | KELLEY | ||||||||
| AuthorizedOfficialFirstName: | CHERYL | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER, CREDENTIALING AND ENROLLME | ||||||||
| AuthorizedOfficialTelephone: | 3139936080 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 5601006086 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.