Healthcare Provider Details

I. General information

NPI: 1568643195
Provider Name (Legal Business Name): HENRY FORD MACOMB HOSPITAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2007
Last Update Date: 12/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15855 19 MILE RD
CLINTON TWP MI
48038-3504
US

IV. Provider business mailing address

215 NORTH AVE
MOUNT CLEMENS MI
48043-1716
US

V. Phone/Fax

Practice location:
  • Phone: 586-263-2705
  • Fax:
Mailing address:
  • Phone: 586-263-2705
  • Fax: 586-263-2255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code276400000X
TaxonomySubstance Use Disorder Rehabilitation Hospital Unit
License Number
License Number State

VIII. Authorized Official

Name: MR. TERRY GOODBALIAN
Title or Position: REGIONAL VP FINANCE, CFO
Credential:
Phone: 586-263-2705