Provider Demographics
NPI:1902842735
Name:HENRY FORD MACOMB HOSPITAL CORPORATION
Entity Type:Organization
Organization Name:HENRY FORD MACOMB HOSPITAL CORPORATION
Other - Org Name:HENRY FORD MACOMB HOSPITAL- WARREN CAMPUS
Other - Org Type:Other Name
Authorized Official - Title/Position:SR. VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:M
Authorized Official - Last Name:CONNELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-874-8714
Mailing Address - Street 1:13355 E 10 MILE RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48089-2048
Mailing Address - Country:US
Mailing Address - Phone:313-874-4633
Mailing Address - Fax:313-847-3943
Practice Address - Street 1:13355 EAST 10 MILE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48089-2048
Practice Address - Country:US
Practice Address - Phone:313-874-4633
Practice Address - Fax:313-847-3943
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-21
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1023114634Medicaid
MI230204OtherMEDICARE PTAN
MI230204OtherMEDICARE PTAN