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General NPI Number Information
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NPI Number | 1801918982
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Entity Type | Organization
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Legal Business Name | PROVIDENCE
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Dates
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Enumeration Date | 04/06/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 662 PURDY ST UNIT 214
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City | BIRMINGHAM
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State | MI
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Zip | 48009-1731
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Country | US
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Telephone | 248-417-4092
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Fax |
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Provider Business Mailing Address
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Address Line | 662 PURDY ST UNIT 214
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City | BIRMINGHAM
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State | MI
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Zip | 48009-1731
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Country | US
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Telephone | 248-417-4092
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Fax |
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Authorized Official
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Title or Position | RESIDENT
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Name | DR. CORY ZACHARY TRIVAX
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Credential |
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Telephone | 248-417-4092
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 282N00000X
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Taxonomy Name | General Acute Care Hospital
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License Number |
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License Number State |
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