Healthcare Provider Details

I. General information

NPI: 1366796567
Provider Name (Legal Business Name): PHOENIX HEALTH CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2012
Last Update Date: 11/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10475 W JEFFERSON AVE
RIVER ROUGE MI
48218-1331
US

IV. Provider business mailing address

10475 W JEFFERSON AVE
RIVER ROUGE MI
48218-1331
US

V. Phone/Fax

Practice location:
  • Phone: 313-342-8421
  • Fax:
Mailing address:
  • Phone: 313-342-8421
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301091092
License Number StateMI

VIII. Authorized Official

Name: DR. GERALD HUDSON
Title or Position: OWNER
Credential: MD
Phone: 313-342-8421