Provider Demographics
NPI:1003844614
Name:BOTSFORD GENERAL HOSPITAL
Entity Type:Organization
Organization Name:BOTSFORD GENERAL HOSPITAL
Other - Org Name:BOTSFORD ONCOLOGY PRACTICE
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR SHARED SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:LESLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLBRANDT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:947-522-1911
Mailing Address - Street 1:26901 BEAUMONT BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:28080 GRAND RIVER AVE
Practice Address - Street 2:SUITE 306
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48336-5966
Practice Address - Country:US
Practice Address - Phone:248-471-8182
Practice Address - Fax:248-478-7179
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-30
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2877555Medicaid
MI110Q246120OtherBLUE CROSS
MI=========014OtherTRICARE