Provider Demographics
NPI:1881891372
Name:PROVIDENCE HOSPITAL
Entity type:Organization
Organization Name:PROVIDENCE HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAMDIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:G
Authorized Official - Last Name:OTSUJI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-849-3447
Mailing Address - Street 1:16400 N.PARK DRIVE APT.1008
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075
Mailing Address - Country:US
Mailing Address - Phone:248-835-7259
Mailing Address - Fax:
Practice Address - Street 1:16400 N PARK DR APT 1008
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-4728
Practice Address - Country:US
Practice Address - Phone:248-835-7259
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes281P00000XHospitalsChronic Disease Hospital