Provider Demographics
NPI:1760561062
Name:UNIVERSITY OF DETROIT MERCY
Entity Type:Organization
Organization Name:UNIVERSITY OF DETROIT MERCY
Other - Org Name:MCAULEY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC COORDINATOR / NP
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:CHAN
Authorized Official - Suffix:
Authorized Official - Credentials:APRN-BC
Authorized Official - Phone:313-579-1182
Mailing Address - Street 1:5555 CONNER ST
Mailing Address - Street 2:STE 2691
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48213-3448
Mailing Address - Country:US
Mailing Address - Phone:313-579-1182
Mailing Address - Fax:313-579-5128
Practice Address - Street 1:5555 CONNER ST
Practice Address - Street 2:STE 2691
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48213-3448
Practice Address - Country:US
Practice Address - Phone:313-579-1182
Practice Address - Fax:313-579-5128
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNIVERSITY OF DETROIT MERCY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-06
Last Update Date:2011-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ON898860Medicare PIN