Provider Demographics
NPI:1184776338
Name:DETROIT MEDICAL CENTER DETROIT RECEIVING HOSPITAL
Entity type:Organization
Organization Name:DETROIT MEDICAL CENTER DETROIT RECEIVING HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SYSTEM EXECUTIVE DIRECTOR, PHARMACY
Authorized Official - Prefix:DR
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:P
Authorized Official - Last Name:HOWARD
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:248-390-2547
Mailing Address - Street 1:4201 SAINT ANTOINE ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2153
Mailing Address - Country:US
Mailing Address - Phone:313-966-8582
Mailing Address - Fax:313-966-6624
Practice Address - Street 1:4201 SAINT ANTOINE ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2153
Practice Address - Country:US
Practice Address - Phone:313-966-8582
Practice Address - Fax:313-966-6624
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301008058282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5170522Medicaid