Provider Demographics
NPI:1780819664
Name:BOTSFORD GENERAL HOSPITAL
Entity Type:Organization
Organization Name:BOTSFORD GENERAL HOSPITAL
Other - Org Name:NORTHSIDE MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR SHARED SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:LESLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLBRANDT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:947-522-1911
Mailing Address - Street 1:26901 BEAUMONT BOULEVARD
Mailing Address - Street 2:STE. 3D
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:947-522-1857
Mailing Address - Fax:
Practice Address - Street 1:14001 GREENFIELD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48227-2101
Practice Address - Country:US
Practice Address - Phone:313-273-1200
Practice Address - Fax:313-273-8130
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BOTSFORD GENERAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-05-21
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0F37116Medicare Oscar/Certification