Provider Demographics
NPI:1154823995
Name:MATERNAL INFANT HEALTH PROVIDERS LLC
Entity Type:Organization
Organization Name:MATERNAL INFANT HEALTH PROVIDERS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:COCHRAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-442-6027
Mailing Address - Street 1:1897 STANLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-4149
Mailing Address - Country:US
Mailing Address - Phone:313-442-6027
Mailing Address - Fax:
Practice Address - Street 1:1897 STANLEY BLVD
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:MI
Practice Address - Zip Code:48009-4149
Practice Address - Country:US
Practice Address - Phone:313-442-6027
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-07
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI=========Medicaid