NPI |
1689658221 |
The 10-position all-numeric identification number assigned by the NPS to uniquely identify a health care provider. The NPI number includes an ISO standard check-digit in the 10th position. There is no intelligence about the health care provider in the number. |
Entity Type Code |
2 |
The 10-position all-numeric identification number assigned by the NPS to uniquely identify a health care provider. The NPI number includes an ISO standard check-digit in the 10th position. There is no intelligence about the health care provider in the number. |
Employer Identification Number EIN |
|
The Employer Identification Number (EIN), assigned by the IRS, of the provider being identified. |
Provider Organization Name Legal Business Name |
HENRY FORD WEST BLOOMFIELD PHYSICIANS |
The Employer Identification Number (EIN), assigned by the IRS, of the provider being identified. |
Provider Other Organization Name |
WALLED LAKE MEDICAL CENTER PC |
Other name by which the organization provider is or has been known. |
Provider Other Organization Name Type Code |
5 |
Other name by which the organization provider is or has been known. |
Provider First Line Business Practice Location Address |
2335 S COMMERCE RD |
The first line location address of the provider
being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box. |
Provider Business Practice Location Address City Name |
WALLED LAKE |
The first line location address of the provider
being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box. |
Provider Business Practice Location Address State Name |
MI |
The State code in the location of the provider
being identified. |
Provider Business Practice Location Address Postal Code |
483902136 |
The State code in the location of the provider
being identified. |
Provider Business Practice Location Address Country Code If outside U S |
US |
The country code in the location address of the provider being identified. |
Provider Business Practice Location Address Telephone Number |
2486241526 |
The country code in the location address of the provider being identified. |
Provider Business Practice Location Address Fax Number |
2486249570 |
The fax number associated with the location
address of the provider being identified. |
Provider Enumeration Date |
12/6/2005 |
The fax number associated with the location
address of the provider being identified. |
Last Update Date |
11/12/2014 |
The date that a record was last updated or changed. |
Authorized Official Last Name |
FENTON |
The date that a record was last updated or changed. |
Authorized Official First Name |
FRANK |
The first name of the authorized official. |
Authorized Official Middle Name |
L |
The first name of the authorized official. |
Authorized Official Title or Position |
PHYSICIAN |
The title or position of the authorized official. |
Authorized Official Telephone Number |
2486241526 |
The title or position of the authorized official. |
Healthcare Provider Taxonomy Code 1 |
207Q00000X |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
Provider License Number 1 |
FF007946 |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
Provider License Number State Code 1 |
MI |
The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number. |
Healthcare Provider Primary Taxonomy Switch 1 |
Y |
The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number. |
Is Organization Subpart |
N |
|
Authorized Official Name Prefix Text |
DR. |
|
Authorized Official Credential Text |
DO |
|
Healthcare Provider Taxonomy Group 1 |
193400000X SINGLE SPECIALTY GROUP |
|