Healthcare Provider Details

I. General information

NPI: 1679808042
Provider Name (Legal Business Name): DETROIT RECEIVING HOSPITAL AND UNIVERSITY HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2009
Last Update Date: 10/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 SAINT ANTOINE ST
DETROIT MI
48201-2153
US

IV. Provider business mailing address

PO BOX 67000 DEPT 614150
DETROIT MI
48267-4150
US

V. Phone/Fax

Practice location:
  • Phone: 313-745-4622
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: GLORIA LARKINS
Title or Position: VICE PRESIDENT OF MICHIGAN
Credential:
Phone: 313-745-2117