Basic Information
| Provider Information | |||||||||
| NPI: | 1912917931 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HENRY FORD MEDICAL CENTER LAKESIDE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14500 HALL RD | ||||||||
| Address2: | |||||||||
| City: | STERLING HEIGHTS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483131229 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 14500 HALL RD | ||||||||
| Address2: | |||||||||
| City: | STERLING HEIGHTS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483131229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5862472700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | CONNELLY | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3138768714 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 41033 | 01 | MI | BLUE CROSS BLUE SHIELD OF | OTHER |