Healthcare Provider Details

I. General information

NPI: 1992848972
Provider Name (Legal Business Name): HENRY FORD MACOMB HOSPITAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 04/23/2021
Certification Date: 04/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43411 GARFIELD RD
CLINTON TOWNSHIP MI
48038-1152
US

IV. Provider business mailing address

215 NORTH AVE
MOUNT CLEMENS MI
48043-1716
US

V. Phone/Fax

Practice location:
  • Phone: 586-226-7007
  • Fax:
Mailing address:
  • Phone: 586-226-7007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number StateMI

VIII. Authorized Official

Name: TERRY A GOODBALIAN
Title or Position: VP CMO
Credential:
Phone: 586-263-2305