=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417983362
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BOTSFORD GENERAL HOSPITAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/23/2006
-----------------------------------------------------
Last Update Date | 05/15/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 28050 GRAND RIVER AVE
-----------------------------------------------------
City | FARMINGTON HILLS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48336-5919
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 947-521-8000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 26901 BEAUMONT BLVD
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48033-3849
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 947-522-1963
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF OPERATING OFFICER
-----------------------------------------------------
Name | NANCY SUSICK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 947-522-3338
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 273R00000X
-----------------------------------------------------
Taxonomy Name | Psychiatric Hospital Unit
-----------------------------------------------------
License Number | 630050
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------