Healthcare Provider Details

I. General information

NPI: 1538575741
Provider Name (Legal Business Name): WAYNE STATE UNIVERSITY-SCHOOL OF MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2014
Last Update Date: 07/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4005, BOURRET AVE, APT 110
MONTREAL QUEBEC
H3S1X1
CA

IV. Provider business mailing address

4005, BOURRET AVE, APT 110
MONTREAL QUEBEC
H3S1X1
CA

V. Phone/Fax

Practice location:
  • Phone: 514-515-8052
  • Fax:
Mailing address:
  • Phone: 514-515-8052
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code281P00000X
TaxonomyChronic Disease Hospital
License Number4301106057
License Number StateMI

VIII. Authorized Official

Name: DR. JOHN JACOBS
Title or Position: PROFESSOR, OTOLARYNGOLOGY
Credential: MD
Phone: 248-218-5557