Basic Information
Provider Information | |||||||||
NPI: | 1871099481 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BAYMARK OF MICHIGAN, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MEDMARK KENTWOOD | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1720 LAKEPOINTE DR STE 170 | ||||||||
Address2: |   | ||||||||
City: | LEWISVILLE | ||||||||
State: | TX | ||||||||
PostalCode: | 750576458 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2143793300 | ||||||||
FaxNumber: | 2145502635 | ||||||||
Practice Location | |||||||||
Address1: | 5500 DIVISION AVENUE SE | ||||||||
Address2: |   | ||||||||
City: | KENTWOOD | ||||||||
State: | MI | ||||||||
PostalCode: | 49548 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2143793300 | ||||||||
FaxNumber: | 2145502635 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/03/2018 | ||||||||
LastUpdateDate: | 02/20/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ANDREWS | ||||||||
AuthorizedOfficialFirstName: | BOND | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VP, RCM | ||||||||
AuthorizedOfficialTelephone: | 2143793379 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2800X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic | 261QR0405X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
ID Information
ID | Type | State | Issuer | Description | OF18038936 | 01 | MI | CERT OF OCCUPANCY | OTHER |