Provider Demographics
NPI:1144210253
Name:ASCENSION PROVIDENCE HOSPITAL
Entity Type:Organization
Organization Name:ASCENSION PROVIDENCE HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:C
Authorized Official - Last Name:WIEMANN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-849-3010
Mailing Address - Street 1:25925 TELEGRAPH RD
Mailing Address - Street 2:STE 210
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-2518
Mailing Address - Country:US
Mailing Address - Phone:248-680-8000
Mailing Address - Fax:248-746-0384
Practice Address - Street 1:47601 GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48374-1233
Practice Address - Country:US
Practice Address - Phone:248-465-4170
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-28
Last Update Date:2020-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
100082OtherCARE CHOICE
934000OtherBEAUMONT
118635OtherGREAT LAKES
00277OtherBLUE CROSS
0061570OtherAETNA
M004776OtherTRICARE
00000001504AOtherCAPE
1015800008OtherBOTSFORD
HL630006OtherMCARE
934000OtherBEAUMONT