Provider Demographics
NPI:1316983000
Name:BOTSFORD GENERAL HOSPITAL
Entity type:Organization
Organization Name:BOTSFORD GENERAL HOSPITAL
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:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:28050 GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48336-5919
Practice Address - Country:US
Practice Address - Phone:248-471-8000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BOTSFORD GENERAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-21
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZC0006XAllopathic & Osteopathic PhysiciansPathologyClinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI00276OtherBLUE CROSS
MI5170228Medicaid
MI230151OtherCARE CHOICES
MI230151OtherHAP
MI230151OtherCARE CHOICES
0F36215Medicare ID - Type UnspecifiedMEDICARE GROUP #