=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689658221
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HENRY FORD WEST BLOOMFIELD PHYSICIANS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/06/2005
-----------------------------------------------------
Last Update Date | 11/12/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2335 S COMMERCE RD
-----------------------------------------------------
City | WALLED LAKE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48390-2136
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-624-1526
-----------------------------------------------------
Fax | 248-624-9570
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2335 S COMMERCE RD
-----------------------------------------------------
City | WALLED LAKE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48390-2136
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-624-1526
-----------------------------------------------------
Fax | 248-624-9570
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | DR. FRANK L FENTON
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 248-624-1526
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | FF007946
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------