Basic Information
Provider Information | |||||||||
NPI: | 1801821988 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WILLIAM BEAUMONT HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BEAUMONT HOME CARE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 26901 BEAUMONT BLVD | ||||||||
Address2: | COMPLIANCE | ||||||||
City: | SOUTHFIELD | ||||||||
State: | MI | ||||||||
PostalCode: | 48071 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9475221964 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1410 E 14 MILE RD | ||||||||
Address2: |   | ||||||||
City: | MADISON HEIGHTS | ||||||||
State: | MI | ||||||||
PostalCode: | 480711541 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2487439500 | ||||||||
FaxNumber: | 2487439111 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/11/2006 | ||||||||
LastUpdateDate: | 10/07/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ODOM | ||||||||
AuthorizedOfficialFirstName: | LEE | ||||||||
AuthorizedOfficialMiddleName: | ANN | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT SHARED SERVICES | ||||||||
AuthorizedOfficialTelephone: | 9475223326 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/07/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X |   |   | Y |   | Agencies | Home Health |   |
ID Information
ID | Type | State | Issuer | Description | OE088 | 01 | MI | BCBS PROVIDER ID# | OTHER | 2592813 | 05 | MI |   | MEDICAID |