Provider Demographics
NPI:1194769828
Name:WAYNE COUNTY AIRPORT AUTHORITY
Entity type:Organization
Organization Name:WAYNE COUNTY AIRPORT AUTHORITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FIRE CHIEF
Authorized Official - Prefix:MR
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:O'SUCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-942-3602
Mailing Address - Street 1:11050 ROGELL DR # 602
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48242-1144
Mailing Address - Country:US
Mailing Address - Phone:734-942-3602
Mailing Address - Fax:734-247-7332
Practice Address - Street 1:DETROIT METRO WILLOW RUN
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48242
Practice Address - Country:US
Practice Address - Phone:734-247-7364
Practice Address - Fax:734-942-3667
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-15
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI821065341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI184590433Medicaid
MIP00146362OtherRR MEDICARE
MI184590433Medicaid