Provider Demographics
NPI:1619332574
Name:DETROIT MEDICAL CENTER
Entity Type:Organization
Organization Name:DETROIT MEDICAL CENTER
Other - Org Name:CHILDREN'S HOSPITAL OF MI
Other - Org Type:Other Name
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER
Authorized Official - Prefix:MS
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:ALLENE
Authorized Official - Last Name:TYUS-BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:313-745-5281
Mailing Address - Street 1:43205 CREEKVIEW DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-3049
Mailing Address - Country:US
Mailing Address - Phone:734-844-7241
Mailing Address - Fax:
Practice Address - Street 1:43205 CREEKVIEW DR
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-3049
Practice Address - Country:US
Practice Address - Phone:734-844-7241
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TENENT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-12-19
Last Update Date:2015-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801067466261QE0700X, 282N00000X, 282NC2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC2000XHospitalsGeneral Acute Care HospitalChildren
No261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
No282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6801067466OtherMICHIGAN LICENSE NUMBER