1104899855 NPI number — SOUTHFIELD ENDOSCOPY ASC LLC

Table of content: DR. SAMANTHA LAUREN BAKER DNP, PMHNP-BC (NPI 1508639816)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104899855 NPI number — SOUTHFIELD ENDOSCOPY ASC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHFIELD ENDOSCOPY ASC LLC
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:
GASTROINTESTINAL ENDOSCOPY CENTER
Provider Other Organization Name Type Code:
3
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:
1104899855
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
264 W MAPLE RD
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
TROY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48084-5435
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-269-5594
Provider Business Mailing Address Fax Number:
248-269-6546

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
264 W MAPLE RD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
TROY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48084-5435
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-269-5594
Provider Business Practice Location Address Fax Number:
248-269-6546
Provider Enumeration Date:
02/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SNODGRASS
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
615-665-1283

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  636911 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 94321929 . This is a "TRICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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