MEDICARE: OAKWOOD AMBULATORY, LLC

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	208000000X	Pediatrics Physician

General Provider Information

NPI Number	:	1962566711
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OAKWOOD AMBULATORY, LLC

Provider Business Mailing Address
First Line	:	26901 BEAUMONT BLVD
Second Line	:
City	:	SOUTHFIELD
State	:	MI
Zip	:	48033-3849
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	18181 OAKWOOD BLVD STE G101
Second Line	:
City	:	DEARBORN
State	:	MI
Zip	:	48124-5031
Country	:	US
Telephone Number	:	313-593-7240
Fax Number	:

Authorized Official
Title or Position	:	SR. DIRECTOR BEAUMONT SHARED SVCS
Name	:	LESLEY WILLBRANDT
Credential	:
Telephone Number	:	947-522-1911

Provider Enumeration Date	:	12/19/2006
Last Update Date	:	06/30/2022

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