Provider Demographics
NPI:1497205272
Name:WILLIAM BEAUMONT HOSPITAL
Entity Type:Organization
Organization Name:WILLIAM BEAUMONT HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT SHARED SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:LEE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:ODOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:947-522-3326
Mailing Address - Street 1:26901 BEAUMONT BLVD
Mailing Address - Street 2:COMPLIANCE
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-4716
Mailing Address - Country:US
Mailing Address - Phone:947-522-1964
Mailing Address - Fax:
Practice Address - Street 1:5150 COOLIDGE HWY
Practice Address - Street 2:BEAUMONT FASTCARE RETAIL MEDICINE
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-1001
Practice Address - Country:US
Practice Address - Phone:248-655-3227
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BEAUMONT FASTCARE RETAIL MEDICINE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-05
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0F37078OtherBCBSM
MI0F359270OtherBCBSM
MI0F37078Medicare PIN
MI0F359270OtherBCBSM