Provider Demographics
NPI:1720265036
Name:CHILDREN'S HOSPITAL
Entity type:Organization
Organization Name:CHILDREN'S HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:HERMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-745-8737
Mailing Address - Street 1:3901 BEAUBIEN ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2119
Mailing Address - Country:US
Mailing Address - Phone:313-578-2564
Mailing Address - Fax:313-578-3964
Practice Address - Street 1:3901 BEAUBIEN ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2119
Practice Address - Country:US
Practice Address - Phone:313-578-2564
Practice Address - Fax:313-578-3964
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-29
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI273Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273Y00000XHospital UnitsRehabilitation Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2788624Medicaid