=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821285321
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HENRY FORD MEDICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/27/2007
-----------------------------------------------------
Last Update Date | 09/27/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2799 W GRAND BLVD
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48202-2608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-916-0466
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2799 W GRAND BLVD
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48202-2608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-916-0466
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SUPERVISOR/CNNP
-----------------------------------------------------
Name | CHRIS NEWMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 313-916-0466
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LN0000X
-----------------------------------------------------
Taxonomy Name | Neonatal Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------