Healthcare Provider Details

I. General information

NPI: 1649490558
Provider Name (Legal Business Name): BRIGHTMOOR MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 09/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20510 FENKELL ROAD
DETROIT MI
48223-1613
US

IV. Provider business mailing address

20510 FENKELL ST PO BOX 23035
DETROIT MI
48223-1613
US

V. Phone/Fax

Practice location:
  • Phone: 313-534-6611
  • Fax: 313-534-2525
Mailing address:
  • Phone: 313-534-6611
  • Fax: 313-534-2525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VH0002X
TaxonomyHospice and Palliative Medicine (Obstetrics & Gynecology) Physician
License Number4301038348
License Number StateMI

VIII. Authorized Official

Name: MR. ALEX PICKENS III
Title or Position: DIRECTOR OF DEVELOPMENT
Credential:
Phone: 313-534-6611