Provider Demographics
NPI:1295953040
Name:DETROIT BIOMED BALDWIN
Entity type:Organization
Organization Name:DETROIT BIOMED BALDWIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:P
Authorized Official - Last Name:ZAKARIA
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:248-471-4111
Mailing Address - Street 1:23955 FREEWAY PARK DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48335-2817
Mailing Address - Country:US
Mailing Address - Phone:248-471-4111
Mailing Address - Fax:248-471-2340
Practice Address - Street 1:1615 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:MI
Practice Address - Zip Code:49304-7984
Practice Address - Country:US
Practice Address - Phone:231-745-8635
Practice Address - Fax:248-471-4111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI002174291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3077860Medicaid
MI=========OtherTAX ID
MI=========OtherTAX ID