Provider Demographics
NPI:1114117447
Name:CONCENTRA MEDICAL CENTER -- CANTON
Entity Type:Organization
Organization Name:CONCENTRA MEDICAL CENTER -- CANTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF MEDICAL OFFIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:W.
Authorized Official - Middle Name:TOM
Authorized Official - Last Name:FOGARTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-364-8000
Mailing Address - Street 1:PO BOX 5106
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48086-5106
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1600 S CANTON CENTER RD
Practice Address - Street 2:SUITE 140
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48188-1992
Practice Address - Country:US
Practice Address - Phone:734-398-7550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OCCUPATIONAL HEALTH CENTERS OF MICHIGAN, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-01
Last Update Date:2007-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy