Healthcare Provider Details

I. General information

NPI: 1689062911
Provider Name (Legal Business Name): HENRY FORD MACOMB ANCILLARY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2015
Last Update Date: 03/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 S MAIN ST
MOUNT CLEMENS MI
48043-2308
US

IV. Provider business mailing address

15855 19 MILE RD ATTN: TERRY GOODBALIAN
CLINTON TOWNSHIP MI
48038-3504
US

V. Phone/Fax

Practice location:
  • Phone: 586-468-1600
  • Fax: 586-465-0329
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License Number
License Number State

VIII. Authorized Official

Name: TERRY GOODBALIAN
Title or Position: VP FINANCE & CFO HFMACOMB
Credential:
Phone: 586-263-2705