Healthcare Provider Details

I. General information

NPI: 1720229065
Provider Name (Legal Business Name): DETROIT MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2009
Last Update Date: 03/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 ST. ANTOINE 6C- UNIVERSITY HEAT CENTER
DETROIT MI
48201
US

IV. Provider business mailing address

4500 CASS AVE APT 922 UNIVERSITY TOWERS
DETROIT MI
48201-1286
US

V. Phone/Fax

Practice location:
  • Phone: 313-577-5009
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number4301092878
License Number StateMI

VIII. Authorized Official

Name: DR. JAMES TYBURSKI
Title or Position: PROGRAM DIRECTOR
Credential:
Phone: 313-577-5009