Provider Demographics
NPI:1619386620
Name:GREATER MACOMB PHO
Entity Type:Organization
Organization Name:GREATER MACOMB PHO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DIRK
Authorized Official - Middle Name:
Authorized Official - Last Name:DELANGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-263-2620
Mailing Address - Street 1:43421 GARFIELD RD
Mailing Address - Street 2:# 203
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1133
Mailing Address - Country:US
Mailing Address - Phone:586-263-2620
Mailing Address - Fax:586-263-2621
Practice Address - Street 1:43421 GARFIELD RD
Practice Address - Street 2:# 203
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-1133
Practice Address - Country:US
Practice Address - Phone:586-263-2620
Practice Address - Fax:586-263-2621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-05
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management