Healthcare Provider Details

I. General information

NPI: 1780649822
Provider Name (Legal Business Name): PROVIDENCE-PROVIDENCE PARK HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 08/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16001 W 9 MILE RD PHYSICIAN BILLING SERVICES
SOUTHFIELD MI
48075-4818
US

IV. Provider business mailing address

2800 LIVERNOIS RD SUITE 500
TROY MI
48083-1215
US

V. Phone/Fax

Practice location:
  • Phone: 248-849-3000
  • Fax: 248-849-2244
Mailing address:
  • Phone: 248-680-8000
  • Fax: 248-680-8032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code163WH1000X
TaxonomyHospice Registered Nurse
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code163WM0102X
TaxonomyMaternal Newborn Registered Nurse
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER JOHNSON
Title or Position: DIRECTOR, CENTRAL BILLING OFFICE
Credential:
Phone: 248-680-8206