Basic Information
| Provider Information | |||||||||
| NPI: | 1982853560 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HENRY FORD WYANDOTTE HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2333 BIDDLE AVE | ||||||||
| Address2: | |||||||||
| City: | WYANDOTTE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481924668 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342466000 | ||||||||
| FaxNumber: | 7342466986 | ||||||||
| Practice Location | |||||||||
| Address1: | 2333 BIDDLE AVE | ||||||||
| Address2: | |||||||||
| City: | WYANDOTTE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481924668 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342466000 | ||||||||
| FaxNumber: | 7342466986 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/18/2008 | ||||||||
| LastUpdateDate: | 09/28/2018 | ||||||||
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| AuthorizedOfficialLastName: | GOODBALIAN | ||||||||
| AuthorizedOfficialFirstName: | TERRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP-FINANCE, FINANCIAL MANAGEMENT | ||||||||
| AuthorizedOfficialTelephone: | 5862632705 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283X00000X | 820230 | MI | Y | Hospitals | Rehabilitation Hospital |
ID Information
| ID | Type | State | Issuer | Description | 00285 | 01 | MI | BLUE CROSS | OTHER | 301892495 | 05 | MI | MEDICAID | 00285 | 01 | MI | BCN | OTHER |