Basic Information
Provider Information | |||||||||
NPI: | 1992725352 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HENRY FORD WYANDOTTE HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | WYANDOTTE HOSPITAL AND MEDICAL CENTER | ||||||||
OtherOrganizationType: | 4 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2333 BIDDLE ST | ||||||||
Address2: |   | ||||||||
City: | WYANDOTTE | ||||||||
State: | MI | ||||||||
PostalCode: | 481924668 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7342466000 | ||||||||
FaxNumber: | 7342466986 | ||||||||
Practice Location | |||||||||
Address1: | 2333 BIDDLE ST | ||||||||
Address2: |   | ||||||||
City: | WYANDOTTE | ||||||||
State: | MI | ||||||||
PostalCode: | 481924668 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7342466000 | ||||||||
FaxNumber: | 7342466986 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/20/2006 | ||||||||
LastUpdateDate: | 09/28/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GOODBALIAN | ||||||||
AuthorizedOfficialFirstName: | TERRY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VP-FINANCE, FINANCIAL MANAGEMENT | ||||||||
AuthorizedOfficialTelephone: | 5862632705 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 820230 | MI | Y |   | Hospitals | General Acute Care Hospital |   |
ID Information
ID | Type | State | Issuer | Description | 00285 | 01 | MI | BLUE CROSS | OTHER | 301892495 | 05 | MI |   | MEDICAID |