=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336661156
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INSTITUTE FOR POPULATION HEALTH INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/13/2017
-----------------------------------------------------
Last Update Date | 12/12/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9053 WOODWARD AVE
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48202-1822
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-309-6707
-----------------------------------------------------
Fax | 313-309-5060
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19830 JAMES COUZENS FWY
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48235-1910
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-309-9350
-----------------------------------------------------
Fax | 313-341-0198
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | GWENDOLYN DANIELS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 313-309-9350
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223D0001X
-----------------------------------------------------
Taxonomy Name | Public Health Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QF0400X
-----------------------------------------------------
Taxonomy Name | Federally Qualified Health Center (FQHC)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------