MEDICARE: CITY OF ECORSE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3416L0300X	Land Ambulance	821005	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	590H200990	OTHER	MI	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1487722682
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CITY OF ECORSE

Provider Business Mailing Address
First Line	:	3869 W JEFFERSON AVE
Second Line	:
City	:	ECORSE
State	:	MI
Zip	:	48229-1701
Country	:	US
Telephone Number	:	313-381-6889
Fax Number	:	313-386-8162

Provider Business Practice Location Address
First Line	:	3869 W JEFFERSON AVE
Second Line	:
City	:	ECORSE
State	:	MI
Zip	:	48229-1701
Country	:	US
Telephone Number	:	313-381-6889
Fax Number	:	313-386-8162

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	FRANKLIN HAYES
Credential	:
Telephone Number	:	313-779-9032

Provider Enumeration Date	:	12/04/2006
Last Update Date	:	12/13/2022

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Directions to “CITY OF ECORSE ” Practice Location

Language	Start Address	Practice Location

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