Provider Demographics
NPI:1003887662
Name:MEDILODGE OF PLYMOUTH, INC.
Entity Type:Organization
Organization Name:MEDILODGE OF PLYMOUTH, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:DENEAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-752-5008
Mailing Address - Street 1:395 W ANN ARBOR TRL
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-1641
Mailing Address - Country:US
Mailing Address - Phone:734-453-3983
Mailing Address - Fax:734-414-8231
Practice Address - Street 1:395 W ANN ARBOR TRL
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-1641
Practice Address - Country:US
Practice Address - Phone:734-453-3983
Practice Address - Fax:734-414-8231
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-31
Last Update Date:2009-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI824320314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3453224Medicaid
MI09839OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MI3453224Medicaid