1538339098 NPI number — MOUNTAIN WEST SURGICAL ASSOCIATES, PROF. LLC

Table of content: (NPI 1538339098)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538339098 NPI number — MOUNTAIN WEST SURGICAL ASSOCIATES, PROF. LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOUNTAIN WEST SURGICAL ASSOCIATES, PROF. 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:
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:
1538339098
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/18/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6255 INKSTER RD
Provider Second Line Business Mailing Address:
SUITE 204
Provider Business Mailing Address City Name:
GARDEN CITY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48135-2577
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-458-4492
Provider Business Mailing Address Fax Number:
734-458-7538

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11600 15 MILE RD
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
STERLING HEIGHTS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48312-5100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-978-2951
Provider Business Practice Location Address Fax Number:
586-979-8758
Provider Enumeration Date:
03/11/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GROSS
Authorized Official First Name:
ROBER
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
734-458-4492

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  RG012468 , 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: 1427143387 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0255011765 . This is a "BCBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".