Provider Demographics
NPI:1609155951
Name:DETROIT MEDICAL CENTER, WAYNE STATE UNIVERSITY, DETROIT, MI
Entity Type:Organization
Organization Name:DETROIT MEDICAL CENTER, WAYNE STATE UNIVERSITY, DETROIT, MI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GRADUATE MEDICAL EDUCATION ASSISTAN
Authorized Official - Prefix:MISS
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:D
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-993-2573
Mailing Address - Street 1:4201 SAINT ANTOINE ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2153
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4201 SAINT ANTOINE ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2153
Practice Address - Country:US
Practice Address - Phone:313-993-2573
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-04
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access