Healthcare Provider Details

I. General information

NPI: 1508218421
Provider Name (Legal Business Name): ORTHOPEDIC MEDICAL BUILDING EAST, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2016
Last Update Date: 07/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28671 HOOVER RD 28673 HOOVER ROAD
WARREN MI
48093-4105
US

IV. Provider business mailing address

28671 HOOVER RD 28673 HOOVER ROAD
WARREN MI
48093-4105
US

V. Phone/Fax

Practice location:
  • Phone: 248-595-8800
  • Fax: 248-595-5817
Mailing address:
  • Phone: 248-595-8800
  • Fax: 248-595-5817

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code146M00000X
TaxonomyIntermediate Emergency Medical Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. IRIS LENA WINCHESTER
Title or Position: C.E.O.
Credential:
Phone: 248-595-8800