Provider Demographics
NPI:1306261391
Name:WILLIAM BEAUMONT HOSPITAL - CRNA
Entity type:Organization
Organization Name:WILLIAM BEAUMONT HOSPITAL - CRNA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT SHARED SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:LEE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:ODOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:947-522-3326
Mailing Address - Street 1:26901 BEAUMONT BLVD
Mailing Address - Street 2:COMPLIANCE
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-4716
Mailing Address - Country:US
Mailing Address - Phone:947-522-1964
Mailing Address - Fax:
Practice Address - Street 1:468 CADIEUX RD
Practice Address - Street 2:BEAUMONT GROSSE POINTE CRNA
Practice Address - City:GROSSE POINTE
Practice Address - State:MI
Practice Address - Zip Code:48230-1507
Practice Address - Country:US
Practice Address - Phone:313-473-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WILLIAM BEAUMONT HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-02-27
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1060000043207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty