Provider Demographics
NPI:1770657785
Name:HEALTH CENTERS DETROIT FOUNDATION, INC.
Entity Type:Organization
Organization Name:HEALTH CENTERS DETROIT FOUNDATION, INC.
Other - Org Name:HEALTH CENTERS DETROIT MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:HERBERT
Authorized Official - Middle Name:C
Authorized Official - Last Name:SMITHERMAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:313-966-5187
Mailing Address - Street 1:4201 SAINT ANTOINE ST
Mailing Address - Street 2:9D
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2153
Mailing Address - Country:US
Mailing Address - Phone:313-966-5187
Mailing Address - Fax:313-966-8111
Practice Address - Street 1:4201 SAINT ANTOINE ST
Practice Address - Street 2:7A
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2153
Practice Address - Country:US
Practice Address - Phone:313-745-4091
Practice Address - Fax:313-966-0993
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI443750261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N71990Medicare PIN