MEDICARE: ELMWOOD GERIATRIC VILLAGE, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility	834980	MI

General Provider Information

NPI Number	:	1225115637
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELMWOOD GERIATRIC VILLAGE, INC

Provider Business Mailing Address
First Line	:	11700 E 10 MILE RD
Second Line	:
City	:	WARREN
State	:	MI
Zip	:	48089-3903
Country	:	US
Telephone Number	:	586-759-5966
Fax Number	:	586-759-8006

Provider Business Practice Location Address
First Line	:	1881 E GRAND BLVD
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48211-3041
Country	:	US
Telephone Number	:	313-922-1600
Fax Number	:	313-922-4756

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. DONALD JAMES BORTZ
Credential	:
Telephone Number	:	586-759-5966

Provider Enumeration Date	:	11/01/2006
Last Update Date	:	08/22/2020

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