=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851583215
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TYRONE CHATMAN ETAL PTR MARTRILLA ROSS GEN PTR
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2007
-----------------------------------------------------
Last Update Date | 08/21/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17650 W 12 MILE RD
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48076-1911
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-871-9940
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17650 W 12 MILE RD
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48076-1911
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-871-9940
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MRS. MARTRILLA MARIE ROSS-CHATMAN
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 313-871-9940
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 4301039079
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------