Provider Demographics
NPI:1669400305
Name:LTAC HOSPITAL DETROIT, LLC
Entity type:Organization
Organization Name:LTAC HOSPITAL DETROIT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-870-9870
Mailing Address - Street 1:801 VIRGINIA PARK ST
Mailing Address - Street 2:THIRD FLOOR
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-1925
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:801 VIRGINIA PARK ST
Practice Address - Street 2:THIRD FLOOR
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-1925
Practice Address - Country:US
Practice Address - Phone:313-870-9870
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIB30526282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI830526OtherST. LIC. NO.