Provider Demographics
NPI:1346407988
Name:PROVIDENCE HOSPITAL
Entity Type:Organization
Organization Name:PROVIDENCE HOSPITAL
Other - Org Name:PH CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR PHYSICIAN BILLING
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:E
Authorized Official - Last Name:WHITMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-746-3218
Mailing Address - Street 1:16001 W 9 MILE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-4818
Mailing Address - Country:US
Mailing Address - Phone:248-849-3000
Mailing Address - Fax:
Practice Address - Street 1:25925 TELEGRAPH RD
Practice Address - Street 2:210
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48033-2518
Practice Address - Country:US
Practice Address - Phone:248-746-3218
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-21
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0F31976OtherBCBSM