Provider Demographics
NPI:1710929468
Name:BOTSFORD GENERAL HOSPTIAL
Entity Type:Organization
Organization Name:BOTSFORD GENERAL HOSPTIAL
Other - Org Name:COMPREHENSIVE OBGYN - DEARBORN HEIGHTS
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT SHARED SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:LEE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:ODOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:947-522-3326
Mailing Address - Street 1:26901 BEAUMONT BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:27031 W WARREN ST
Practice Address - Street 2:
Practice Address - City:DEARBORN HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48127-1901
Practice Address - Country:US
Practice Address - Phone:313-561-1913
Practice Address - Fax:313-561-2196
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOF37116OtherBLUE CROSS
MIOF37116OtherBLUE CROSS
MIOM30990Medicare ID - Type Unspecified