1053439117 NPI number — OUTPATIENT ENDOSCOPY & SURGI CENTER

Table of content: (NPI 1053439117)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053439117 NPI number — OUTPATIENT ENDOSCOPY & SURGI CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OUTPATIENT ENDOSCOPY & SURGI CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053439117
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
28300 HARPER AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT CLAIR SHORES
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48081-1686
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-778-6090
Provider Business Mailing Address Fax Number:
586-778-1943

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
28300 HARPER AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT CLAIR SHORES
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48081-1686
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-778-6090
Provider Business Practice Location Address Fax Number:
586-778-1943
Provider Enumeration Date:
03/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PANDYA
Authorized Official First Name:
HARIVALLABH
Authorized Official Middle Name:
D
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
586-778-6090

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  506821 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 261QE0800X , with the licence number: 506821 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)





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