Provider Demographics
NPI:1689658221
Name:HENRY FORD WEST BLOOMFIELD PHYSICIANS
Entity Type:Organization
Organization Name:HENRY FORD WEST BLOOMFIELD PHYSICIANS
Other - Org Name:WALLED LAKE MEDICAL CENTER PC
Other - Org Type:Other Name
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:L
Authorized Official - Last Name:FENTON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:248-624-1526
Mailing Address - Street 1:2335 S COMMERCE RD
Mailing Address - Street 2:
Mailing Address - City:WALLED LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48390-2136
Mailing Address - Country:US
Mailing Address - Phone:248-624-1526
Mailing Address - Fax:248-624-9570
Practice Address - Street 1:2335 S COMMERCE RD
Practice Address - Street 2:
Practice Address - City:WALLED LAKE
Practice Address - State:MI
Practice Address - Zip Code:48390-2136
Practice Address - Country:US
Practice Address - Phone:248-624-1526
Practice Address - Fax:248-624-9570
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-06
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIFF007946207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty