Provider Demographics
NPI:1093943615
Name:PROVIDENCE HOSPITAL
Entity Type:Organization
Organization Name:PROVIDENCE HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RESIDENT PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:KAI
Authorized Official - Middle Name:KINYELL
Authorized Official - Last Name:PALM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-622-5004
Mailing Address - Street 1:11692 BEAVERLAND
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48239-1357
Mailing Address - Country:US
Mailing Address - Phone:313-622-5004
Mailing Address - Fax:248-849-5389
Practice Address - Street 1:22250 PROVIDENCE DR
Practice Address - Street 2:SUITE 500
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-4825
Practice Address - Country:US
Practice Address - Phone:248-849-3447
Practice Address - Fax:248-849-5389
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-23
Last Update Date:2009-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301094326261Q00000X, 261QP2300X, 282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care