=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871907303
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BOTSFORD GENERAL HOSPITAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2014
-----------------------------------------------------
Last Update Date | 08/21/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 28080 GRAND RIVER AVE SUITE 306
-----------------------------------------------------
City | FARMINGTON HILLS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48336-5966
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 947-522-4771
-----------------------------------------------------
Fax | 248-473-4772
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 26901 BEAUMONT BLVD
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48033-3849
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR SHARED SERVICES
-----------------------------------------------------
Name | LESLEY WILLBRANDT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 947-522-1911
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------