Provider Demographics
NPI:1598825440
Name:CITY OF DETROIT
Entity Type:Organization
Organization Name:CITY OF DETROIT
Other - Org Name:DEPARTMENT OF HEALTH AND WELLNESS PROMOTION
Other - Org Type:Other Name
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JONEIGH
Authorized Official - Middle Name:
Authorized Official - Last Name:KHALDUN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-876-0000
Mailing Address - Street 1:1151 TAYLOR ST
Mailing Address - Street 2:ROOM 349C
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-1732
Mailing Address - Country:US
Mailing Address - Phone:313-876-4710
Mailing Address - Fax:313-876-0177
Practice Address - Street 1:3245 E JEFFERSON AVE STE 100
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-4222
Practice Address - Country:US
Practice Address - Phone:313-876-4710
Practice Address - Fax:313-876-0177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4456991Medicaid
MIOH21592Medicare ID - Type UnspecifiedDETROIT DEPARTMENT OF HEA
MIOH26164Medicare ID - Type Unspecified
MI4456991Medicaid