Provider Demographics
NPI:1992848972
Name:HENRY FORD MACOMB HOSPITAL CORPORATION
Entity Type:Organization
Organization Name:HENRY FORD MACOMB HOSPITAL CORPORATION
Other - Org Name:HENRY FORD MACOMB HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP CMO
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:A
Authorized Official - Last Name:GOODBALIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-263-2305
Mailing Address - Street 1:215 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT CLEMENS
Mailing Address - State:MI
Mailing Address - Zip Code:48043-1716
Mailing Address - Country:US
Mailing Address - Phone:586-226-7007
Mailing Address - Fax:
Practice Address - Street 1:43411 GARFIELD RD
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-1152
Practice Address - Country:US
Practice Address - Phone:586-226-7007
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI103T00000X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI680E062890OtherBLUE CROSS GROUP NUMBER
MI680E062890OtherBLUE CROSS GROUP NUMBER