Healthcare Provider Details

I. General information

NPI: 1710876099
Provider Name (Legal Business Name): ROGER BURNEY CHW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2025
Last Update Date: 07/01/2025
Certification Date: 07/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 W 7 MILE RD
DETROIT MI
48203-1968
US

IV. Provider business mailing address

13901 E JEFFERSON AVE
DETROIT MI
48215-2720
US

V. Phone/Fax

Practice location:
  • Phone: 313-368-2600
  • Fax: 313-369-2477
Mailing address:
  • Phone: 313-821-2591
  • Fax: 313-822-0900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: