Basic Information
| Provider Information | |||||||||
| NPI: | 1811271620 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HENRY FORD HEALTH SYSTEM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 FORD PL | ||||||||
| Address2: | SUITE 2E | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482023450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138744806 | ||||||||
| FaxNumber: | 3138744677 | ||||||||
| Practice Location | |||||||||
| Address1: | 2799 W GRAND BLVD | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482022608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3139162600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2011 | ||||||||
| LastUpdateDate: | 09/29/2011 | ||||||||
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| AuthorizedOfficialLastName: | NANTAIS | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3138744806 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | COO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.