Healthcare Provider Details

I. General information

NPI: 1912379751
Provider Name (Legal Business Name): MICHIGAN DEPARTMENT OF CORRECTIONS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2015
Last Update Date: 10/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17600 RYAN RD
DETROIT MI
48212-1155
US

IV. Provider business mailing address

17600 RYAN RD
DETROIT MI
48212-1155
US

V. Phone/Fax

Practice location:
  • Phone: 313-368-3200
  • Fax: 313-368-6015
Mailing address:
  • Phone: 313-368-3200
  • Fax: 313-368-6015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number2901014477
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number2901014477
License Number StateMI

VIII. Authorized Official

Name: DR. JONG CHOI
Title or Position: REGIONAL DENTAL DIRECTOR
Credential:
Phone: 517-780-5760