Provider Demographics
NPI:1346391539
Name:DETROIT MEDICAL CENTER
Entity Type:Organization
Organization Name:DETROIT MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF LABORATORY SERVIC
Authorized Official - Prefix:MS
Authorized Official - First Name:VERDELL
Authorized Official - Middle Name:
Authorized Official - Last Name:TOLBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-993-0724
Mailing Address - Street 1:4201 SAINT ANTOINE ST
Mailing Address - Street 2:2C UHC
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2153
Mailing Address - Country:US
Mailing Address - Phone:313-993-0724
Mailing Address - Fax:313-745-9661
Practice Address - Street 1:4201 SAINT ANTOINE ST
Practice Address - Street 2:2C UHC
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2153
Practice Address - Country:US
Practice Address - Phone:313-993-0724
Practice Address - Fax:313-745-9661
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-15
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2888352Medicaid
MI0H22475Medicare ID - Type Unspecified