Basic Information
| Provider Information | |||||||||
| NPI: | 1881891372 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROVIDENCE HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16400 N.PARK DRIVE APT.1008 | ||||||||
| Address2: | |||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48075 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488357259 | ||||||||
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| Practice Location | |||||||||
| Address1: | 16400 N PARK DR APT 1008 | ||||||||
| Address2: | |||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480754728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488357259 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | OTSUJI | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | PROGRAMDIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2488493447 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 281P00000X | Y | Hospitals | Chronic Disease Hospital |
No ID Information.