Provider Demographics
NPI:1053462846
Name:CASCOR HEALTH SYSTEMS PC
Entity Type:Organization
Organization Name:CASCOR HEALTH SYSTEMS PC
Other - Org Name:EAST PARK MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SAI
Authorized Official - Middle Name:
Authorized Official - Last Name:WENTUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-368-4600
Mailing Address - Street 1:4821 MCNICHOLS ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48212-1730
Mailing Address - Country:US
Mailing Address - Phone:313-368-4600
Mailing Address - Fax:313-368-4700
Practice Address - Street 1:4821 MCNICHOLS ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48212-1730
Practice Address - Country:US
Practice Address - Phone:313-368-4600
Practice Address - Fax:313-368-4700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2011-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI049430207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4529149Medicaid
MI0P06500Medicare ID - Type Unspecified
MI4529149Medicaid