Provider Demographics
NPI:1821267832
Name:EASTLAKE MEDICAL CENTER
Entity Type:Organization
Organization Name:EASTLAKE MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:BIANCA
Authorized Official - Middle Name:FELICIA
Authorized Official - Last Name:DOOLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-747-3425
Mailing Address - Street 1:17520 W 12 MILE RD STE 116
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-1907
Mailing Address - Country:US
Mailing Address - Phone:248-443-6711
Mailing Address - Fax:
Practice Address - Street 1:646 CHENE ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-3979
Practice Address - Country:US
Practice Address - Phone:248-747-3425
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-23
Last Update Date:2008-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty