Provider Demographics
NPI:1063767713
Name:CHILDREN'S HOSPITAL OF MICHIGAN
Entity type:Organization
Organization Name:CHILDREN'S HOSPITAL OF MICHIGAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC RESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEISUKE
Authorized Official - Middle Name:
Authorized Official - Last Name:UEDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-532-3410
Mailing Address - Street 1:3901 BEAUBIEN ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2119
Mailing Address - Country:US
Mailing Address - Phone:313-745-5437
Mailing Address - Fax:
Practice Address - Street 1:3901 BEAUBIEN ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2119
Practice Address - Country:US
Practice Address - Phone:313-745-5437
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-18
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301007841261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care