Provider Demographics
NPI:1861720609
Name:WORCESTER HOME
Entity type:Organization
Organization Name:WORCESTER HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:MARYLIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-996-0604
Mailing Address - Street 1:24922 INDEPENDENCE DR APT 6208
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48335-1744
Mailing Address - Country:US
Mailing Address - Phone:248-996-0604
Mailing Address - Fax:
Practice Address - Street 1:24922 INDEPENDENCE DR APT 6208
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48335-1744
Practice Address - Country:US
Practice Address - Phone:248-996-0604
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-04
Last Update Date:2009-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI716877305R00000X, 302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
No305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI716877Medicaid
MI716877Medicare Oscar/Certification