Provider Demographics
NPI:1184174963
Name:WILLIAM BEAUMONT HOSPITAL
Entity type:Organization
Organization Name:WILLIAM BEAUMONT HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT SHARED SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:LEE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:ODOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:947-522-3326
Mailing Address - Street 1:26901 BEAUMONT BLVD
Mailing Address - Street 2:COMPLIANCE
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-4716
Mailing Address - Country:US
Mailing Address - Phone:947-522-1964
Mailing Address - Fax:
Practice Address - Street 1:6900 ORCHARD LAKE RD STE 100
Practice Address - Street 2:BEAUMONT URGENT CARE
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-3424
Practice Address - Country:US
Practice Address - Phone:248-855-4134
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BEAUMONT URGENT CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-05
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI363A00000X, 363L00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0F359270OtherBCBSM
MI0F399250OtherBCBSM
MI0F362410OtherBCBSM
MI0F359270OtherBCBSM
MI0F362410OtherBCBSM
MI0F399250OtherBCBSM