Provider Demographics
NPI:1821250184
Name:WAYNE COUNTY HEALTH DEPARTMENT
Entity Type:Organization
Organization Name:WAYNE COUNTY HEALTH DEPARTMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTING SUPERVISOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:BANASZAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-727-7208
Mailing Address - Street 1:33030 VAN BORN RD
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:MI
Mailing Address - Zip Code:48184-2453
Mailing Address - Country:US
Mailing Address - Phone:734-727-7208
Mailing Address - Fax:737-727-7005
Practice Address - Street 1:33030 VAN BORN RD
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:MI
Practice Address - Zip Code:48184-2453
Practice Address - Country:US
Practice Address - Phone:734-727-7208
Practice Address - Fax:737-727-7005
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAYNE COUNTY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-06-27
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901012332122300000X
MI2901011217122300000X
MI2901010538122300000X
122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI741846106Medicaid
MI744045109Medicaid
MI744054000Medicaid