Healthcare Provider Details

I. General information

NPI: 1134398027
Provider Name (Legal Business Name): SOUTHEASTERN MICHIGAN HEALTH ASSOCIATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2008
Last Update Date: 07/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11447 JOSEPH CAMPAU
HAMTRAMCK MI
48212
US

IV. Provider business mailing address

3011 WEST GRAND BOULEVARD SUITE 200
DETROIT MI
48202
US

V. Phone/Fax

Practice location:
  • Phone: 313-365-1362
  • Fax: 313-365-1350
Mailing address:
  • Phone: 313-873-6500
  • Fax: 313-873-8137

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: THOMAS CIESZYNSKI
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 313-873-6500