Provider Demographics
NPI:1366832511
Name:HENRY FORD HEALTH SYSTEM
Entity type:Organization
Organization Name:HENRY FORD HEALTH SYSTEM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHOPAEDIC SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:LEISE
Authorized Official - Last Name:PACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:810-348-7907
Mailing Address - Street 1:2333 BIDDLE AVE.
Mailing Address - Street 2:HENRY FORD WYANDOTTE HOSPITAL
Mailing Address - City:WYANDOTTE
Mailing Address - State:MI
Mailing Address - Zip Code:48192-9552
Mailing Address - Country:US
Mailing Address - Phone:734-246-6036
Mailing Address - Fax:
Practice Address - Street 1:2333 BIDDLE AVENUE
Practice Address - Street 2:HENRY FORD WYANDOTTE HOSPITAL
Practice Address - City:WYANDOTTE
Practice Address - State:MI
Practice Address - Zip Code:48192
Practice Address - Country:US
Practice Address - Phone:734-246-6036
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-27
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010335400261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center