# MEDILODGE OF PLYMOUTH, INC.

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1003887662
- **Authorized official:** KATHLEEN DENEAN (CHIEF EXECUTIVE OFFICER)
- **Authorized official phone:** (586) 752-5008

## Contact information

- **Practice address:** 395 W ANN ARBOR TRL, PLYMOUTH, MI 48170-1641
- **Practice address phone:** (734) 453-3983
- **Practice address fax:** (734) 414-8231
- **Mailing address:** 395 W ANN ARBOR TRL, PLYMOUTH, MI 48170-1641
- **Mailing address phone:** (734) 453-3983
- **Mailing address fax:** (734) 414-8231

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 314000000X | Skilled Nursing Facility | 824320 | MI | Yes |

## Other

- **Enumeration date:** 01/31/2006
- **Last updated:** 07/16/2009

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 09839 | BLUE CROSS BLUE SHIELD OF MICHIGAN | MI |
| 05 | — | 3453224 | — | MI |