Provider Demographics
NPI:1720072812
Name:PROFESSIONAL HOME CARE DEARBORN OXYGEN THERAPY CO
Entity Type:Organization
Organization Name:PROFESSIONAL HOME CARE DEARBORN OXYGEN THERAPY CO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:G
Authorized Official - Last Name:KOLFAGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-277-2160
Mailing Address - Street 1:24706 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-1750
Mailing Address - Country:US
Mailing Address - Phone:313-277-2160
Mailing Address - Fax:313-277-3079
Practice Address - Street 1:24706 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-1750
Practice Address - Country:US
Practice Address - Phone:313-277-2160
Practice Address - Fax:313-277-3079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-06
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5306000370332100000X
332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332100000XSuppliersDepartment of Veterans Affairs (VA) Pharmacy
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0536970001Medicare NSC