Provider Demographics
NPI:1568643195
Name:HENRY FORD MACOMB HOSPITAL CORPORATION
Entity Type:Organization
Organization Name:HENRY FORD MACOMB HOSPITAL CORPORATION
Other - Org Name:HENRY FORD MACOMB HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGIONAL VP FINANCE, CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODBALIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-263-2705
Mailing Address - Street 1:215 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT CLEMENS
Mailing Address - State:MI
Mailing Address - Zip Code:48043-1716
Mailing Address - Country:US
Mailing Address - Phone:586-263-2705
Mailing Address - Fax:586-263-2255
Practice Address - Street 1:15855 19 MILE RD
Practice Address - Street 2:
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48038-3504
Practice Address - Country:US
Practice Address - Phone:586-263-2705
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-26
Last Update Date:2010-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes276400000XHospital UnitsRehabilitation, Substance Use Disorder Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI20315OtherBCBS OP SUBSTANCE ABUSE