1700967106 NPI number — EBSC, LLC

Table of content: (NPI 1700967106)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700967106 NPI number — EBSC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EBSC, 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:
SURGICAL CARE CENTER OF MICHIGAN
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:
1700967106
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/03/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
750 EAST BELTLINE NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49525-6049
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-940-3600
Provider Business Mailing Address Fax Number:
616-954-0216

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
750 EAST BELTLINE NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND RAPIDS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49525-6049
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-940-3600
Provider Business Practice Location Address Fax Number:
616-954-0213
Provider Enumeration Date:
10/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KILGORE
Authorized Official First Name:
KRISTINE
Authorized Official Middle Name:
PATRICE
Authorized Official Title or Position:
ADMINISTRATICE DIRECTOR
Authorized Official Telephone Number:
616-580-6520

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QA1903X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 490001454 . This is a "MEDICARE RR" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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