Provider Demographics
NPI:1780649822
Name:PROVIDENCE-PROVIDENCE PARK HOSPITAL
Entity Type:Organization
Organization Name:PROVIDENCE-PROVIDENCE PARK HOSPITAL
Other - Org Name:PH NURSE PRACTITIONERS/PROVIDENCE HOSPITAL AND MEDICAL CENTERS INC
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR, CENTRAL BILLING OFFICE
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-680-8206
Mailing Address - Street 1:2800 LIVERNOIS RD
Mailing Address - Street 2:SUITE 500
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1215
Mailing Address - Country:US
Mailing Address - Phone:248-680-8000
Mailing Address - Fax:248-680-8032
Practice Address - Street 1:16001 W 9 MILE RD
Practice Address - Street 2:PHYSICIAN BILLING SERVICES
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-4818
Practice Address - Country:US
Practice Address - Phone:248-849-3000
Practice Address - Fax:248-849-2244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-20
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care MedicineGroup - Multi-Specialty
No163WH1000XNursing Service ProvidersRegistered NurseHospiceGroup - Multi-Specialty
No163WM0102XNursing Service ProvidersRegistered NurseMaternal NewbornGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI500F319040OtherMI BLUE CROSS GROUP PIN #
MI500F319040OtherMI BLUE CROSS GROUP PIN #