Healthcare Provider Details

I. General information

NPI: 1558519827
Provider Name (Legal Business Name): CHILDREN'S HOSPITAL OF MICHIGAN, DETROIT MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2008
Last Update Date: 08/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 BEAUBIEN ST CHILDREN'S HOSPITAL OF MICHIGAN
DETROIT MI
48201-2119
US

IV. Provider business mailing address

4500 CASS AVE APARTMENT NO. 617, UNIVERSITY TOWERS
DETROIT MI
48201-1288
US

V. Phone/Fax

Practice location:
  • Phone: 313-745-5638
  • Fax:
Mailing address:
  • Phone: 313-715-0162
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NC2000X
TaxonomyChildren's Hospital
License Number4301092198
License Number StateMI

VIII. Authorized Official

Name: DR. ANNE M. MORTENSEN
Title or Position: DIRECTOR, PEDIATRIC RESIDENCY
Credential: M.D
Phone: 313-966-0254