Basic Information
Provider Information | |||||||||
NPI: | 1821310806 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | OAKWOOD HEALTHCARE INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | OAKWOOD OUTPATIENT DIALYSIS CENTER | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 26901 BEAUMONT BLVD. | ||||||||
Address2: | COMPLIANCE | ||||||||
City: | SOUTHFIELD | ||||||||
State: | MI | ||||||||
PostalCode: | 480334716 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9475221963 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 18100 OAKWOOD BLVD | ||||||||
Address2: | SUITE 206 | ||||||||
City: | DEARBORN | ||||||||
State: | MI | ||||||||
PostalCode: | 481244085 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3134387969 | ||||||||
FaxNumber: | 3134387960 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/18/2010 | ||||||||
LastUpdateDate: | 10/13/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ODOM | ||||||||
AuthorizedOfficialFirstName: | LEE | ||||||||
AuthorizedOfficialMiddleName: | ANN | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT SHARED SERVICES | ||||||||
AuthorizedOfficialTelephone: | 9475223326 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | OAKWOOD HEALTHCARE INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/13/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | 820120 | MI | Y |   | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
ID | Type | State | Issuer | Description | 23-2351 | 01 | MI | CCN 23-2351 | OTHER |