Provider Demographics
NPI:1982611562
Name:DETROIT COMMUNITY HEALTH CONNECTION, INC.
Entity type:Organization
Organization Name:DETROIT COMMUNITY HEALTH CONNECTION, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:MAHIPAL
Authorized Official - Middle Name:RAO
Authorized Official - Last Name:KAKARALA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-821-2591
Mailing Address - Street 1:13901 E JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48215-2720
Mailing Address - Country:US
Mailing Address - Phone:313-821-2591
Mailing Address - Fax:313-822-4202
Practice Address - Street 1:13901 E JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48215-2720
Practice Address - Country:US
Practice Address - Phone:313-822-0900
Practice Address - Fax:313-822-0950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1992196Medicaid
1982611562OtherNPI
231802Medicare Oscar/Certification