Provider Demographics
NPI:1356403505
Name:OAKWOOD AMBULATORY, LLC
Entity type:Organization
Organization Name:OAKWOOD AMBULATORY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR. DIRECTOR BEAUMONT SHARED SVCS
Authorized Official - Prefix:
Authorized Official - First Name:LESLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLBRANDT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:947-522-1911
Mailing Address - Street 1:26901 BEAUMONT BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16351 ROTUNDA
Practice Address - Street 2:STE 168
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48120-2005
Practice Address - Country:US
Practice Address - Phone:313-253-9781
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0N84060Medicare ID - Type Unspecified