=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659391043
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HENRY FORD HEALTH SYSTEM
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/20/2006
-----------------------------------------------------
Last Update Date | 02/24/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 44200 WOODWARD AVE SUITE 109
-----------------------------------------------------
City | PONTIAC
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48341-5045
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-322-7253
-----------------------------------------------------
Fax | 248-322-0311
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 30100 TELEGRAPH RD SUITE 200
-----------------------------------------------------
City | BINGHAM FARMS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48025-4516
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-723-0224
-----------------------------------------------------
Fax | 248-642-7852
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT
-----------------------------------------------------
Name | MR. DAVID F SHEPHERD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 248-642-5038
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QE0700X
-----------------------------------------------------
Taxonomy Name | End-Stage Renal Disease (ESRD) Treatment Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------