Provider Demographics
NPI:1689815300
Name:DETROIT MEDICAL CENTER
Entity Type:Organization
Organization Name:DETROIT MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:G
Authorized Official - Last Name:TYBURSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-745-3487
Mailing Address - Street 1:1431 WASHINGTON BLVD
Mailing Address - Street 2:APT 1814
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48226-1732
Mailing Address - Country:US
Mailing Address - Phone:313-525-2072
Mailing Address - Fax:
Practice Address - Street 1:1431 WASHINGTON BLVD
Practice Address - Street 2:APT 1814
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48226-1732
Practice Address - Country:US
Practice Address - Phone:313-525-2072
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-09
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIBH26634487029OtherDEA