Healthcare Provider Details

I. General information

NPI: 1184174963
Provider Name (Legal Business Name): WILLIAM BEAUMONT HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2016
Last Update Date: 10/01/2021
Certification Date: 10/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6900 ORCHARD LAKE RD STE 100 BEAUMONT URGENT CARE
WEST BLOOMFIELD MI
48322-3424
US

IV. Provider business mailing address

26901 BEAUMONT BLVD COMPLIANCE
SOUTHFIELD MI
48033-4716
US

V. Phone/Fax

Practice location:
  • Phone: 248-855-4134
  • Fax:
Mailing address:
  • Phone: 947-522-1964
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateMI

VIII. Authorized Official

Name: LEE ANN ODOM
Title or Position: PRESIDENT SHARED SERVICES
Credential:
Phone: 947-522-3326