Provider Demographics
NPI:1093828303
Name:BOTSFORD GENERAL HOSPITAL
Entity Type:Organization
Organization Name:BOTSFORD GENERAL HOSPITAL
Other - Org Name:BOTSFORD PODIATRY CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:SUSICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:947-522-3338
Mailing Address - Street 1:26901 BEAUMONT BLVD STE 3D
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 1:28100 GRAND RIVER AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48336-5967
Practice Address - Country:US
Practice Address - Phone:947-521-1320
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BOTSFORD GENERAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-17
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI110H299920OtherBLUE CROSS BLUE SHIELD
230151Medicare Oscar/Certification
0F37181Medicare PIN
MI110H299920OtherBLUE CROSS BLUE SHIELD
MI2664150003Medicare Oscar/Certification
MI2664150003Medicare PIN