Provider Demographics
NPI:1063790186
Name:DETROIT COMMUNITY HEALTH CONNECTION, INC
Entity type:Organization
Organization Name:DETROIT COMMUNITY HEALTH CONNECTION, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SRVP/CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:MAHIPAL
Authorized Official - Middle Name:RAO
Authorized Official - Last Name:KAKARALA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-821-2591
Mailing Address - Street 1:12800 E WARREN AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48215-2061
Mailing Address - Country:US
Mailing Address - Phone:313-343-2887
Mailing Address - Fax:313-343-2889
Practice Address - Street 1:12800 E WARREN AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48215-2061
Practice Address - Country:US
Practice Address - Phone:313-343-2887
Practice Address - Fax:313-343-2889
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DETROIT COMMUNITY HEALTH CONNECTION, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-07-22
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MION30150OtherMEDICARE ID
MI1992196Medicaid
MI231802Medicare Oscar/Certification