1457503781 NPI number — OAKWOOD HEALHCARE GROUP 1, LLC

Table of content: (NPI 1457503781)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457503781 NPI number — OAKWOOD HEALHCARE GROUP 1, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OAKWOOD HEALHCARE GROUP 1, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SOUTHSHORE MOB
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457503781
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/21/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
29601 BEAUMONT BLVD
Provider Second Line Business Mailing Address:
COMPLIANCE
Provider Business Mailing Address City Name:
SOUTHFIELD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48033-3849
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
947-522-1964
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5400 FORT ST
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
TRENTON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48183-4632
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-362-1200
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/17/2008

Additional Information

Authorized Official

Authorized Official Last Name:
ODOM
Authorized Official First Name:
LEE
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
PRESIDENT SHARED SERVICES
Authorized Official Telephone Number:
947-522-3326

Provider Taxonomy Codes

  • Taxonomy code: 207VX0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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