Provider Demographics
NPI:1285871954
Name:WAYNE COUNTY PATIENT CARE MANAGEMENT SYSTEM
Entity type:Organization
Organization Name:WAYNE COUNTY PATIENT CARE MANAGEMENT SYSTEM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:GRUNDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-833-3430
Mailing Address - Street 1:640 TEMPLE ST
Mailing Address - Street 2:SUITE 370
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2599
Mailing Address - Country:US
Mailing Address - Phone:313-833-3430
Mailing Address - Fax:
Practice Address - Street 1:640 TEMPLE ST
Practice Address - Street 2:SUITE 370
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2599
Practice Address - Country:US
Practice Address - Phone:313-833-3430
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-16
Last Update Date:2009-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4527725251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4527725Medicaid