Basic Information
| Provider Information | |||||||||
| NPI: | 1679522973 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WILLIAM BEAUMONT HOSPITAL | ||||||||
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| OtherOrganizationName: | WILLIAM BEAUMONT HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26901 BEAUMONT BOULEVARD | ||||||||
| Address2: | COMPLINANCE | ||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480333849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9475221964 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3601 W 13 MILE RD | ||||||||
| Address2: | |||||||||
| City: | ROYAL OAK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480736712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488985000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2006 | ||||||||
| LastUpdateDate: | 05/12/2021 | ||||||||
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| AuthorizedOfficialLastName: | WILLBRANDT | ||||||||
| AuthorizedOfficialFirstName: | LESLEY | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR SHARED SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 9475221911 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WILLIAM BEAUMONT HOSPITAL | ||||||||
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| NPICertificationDate: | 04/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RR0500X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology |
ID Information
| ID | Type | State | Issuer | Description | 0F36136 | 01 | MI | BCBSM GROUP | OTHER |