Provider Demographics
NPI:1689062911
Name:HENRY FORD MACOMB ANCILLARY SERVICES
Entity Type:Organization
Organization Name:HENRY FORD MACOMB ANCILLARY SERVICES
Other - Org Name:HENRY FORD MACOMB IMAGING CENTER-MT. CLEMENS
Other - Org Type:Other Name
Authorized Official - Title/Position:VP FINANCE & CFO HFMACOMB
Authorized Official - Prefix:
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 1:15855 19 MILE RD
Mailing Address - Street 2:ATTN: TERRY GOODBALIAN
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-3504
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:133 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MOUNT CLEMENS
Practice Address - State:MI
Practice Address - Zip Code:48043-2308
Practice Address - Country:US
Practice Address - Phone:586-468-1600
Practice Address - Fax:586-465-0329
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HENRY FORD MACOMB HOSPITAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-01-09
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiologyGroup - Multi-Specialty
No293D00000XLaboratoriesPhysiological Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6249440001Medicare NSC
MIOM332000Medicare PIN