Healthcare Provider Details

I. General information

NPI: 1063701522
Provider Name (Legal Business Name): WAYNE STATE UNIVERSITY SCHOOL OF MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2011
Last Update Date: 06/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 WESTVIEW DR SW
ATLANTA GA
30310-1458
US

IV. Provider business mailing address

540 E CANFIELD ST
DETROIT MI
48201-1928
US

V. Phone/Fax

Practice location:
  • Phone: 404-616-1424
  • Fax:
Mailing address:
  • Phone: 313-577-5245
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number
License Number State

VIII. Authorized Official

Name: DR. MARTHA JORDAN
Title or Position: ADMINISTRATIVE DIRECTOR
Credential:
Phone: 313-577-2378