Basic Information
| Provider Information | |||||||||
| NPI: | 1568861557 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HENRY FORD WYANDOTTE HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 FORD PL STE 2E | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482023450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138744806 | ||||||||
| FaxNumber: | 3487613057 | ||||||||
| Practice Location | |||||||||
| Address1: | 23050 WEST RD STE 240 | ||||||||
| Address2: | |||||||||
| City: | BROWNSTOWN TWP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481831473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342814197 | ||||||||
| FaxNumber: | 7342820093 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2014 | ||||||||
| LastUpdateDate: | 03/19/2021 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
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| AuthorizedOfficialTitleorPosition: | SVP | ||||||||
| AuthorizedOfficialTelephone: | 5172056407 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 03/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207YP0228X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | Pediatric Otolaryngology | 207YX0602X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | Otolaryngic Allergy | 231H00000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist | 207Y00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 0H29003 AUDIOLOGIST | 01 | MI | BLUE CROSS PIN AUDIOLOGIST | OTHER | 0H28800 | 01 | MI | BLUE CROSS | OTHER |