1952576431 NPI number — NORTHEAST SURGICAL SPECIALISTS, PC

Table of content: (NPI 1952576431)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952576431 NPI number — NORTHEAST SURGICAL SPECIALISTS, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHEAST SURGICAL SPECIALISTS, PC
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:
1952576431
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/21/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
43211 DALCOMA DR
Provider Second Line Business Mailing Address:
SUIT 4
Provider Business Mailing Address City Name:
CLINTON TWP
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48038-6309
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-286-8800
Provider Business Mailing Address Fax Number:
586-286-8068

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
43211 DALCOMA DR
Provider Second Line Business Practice Location Address:
SUITE 4
Provider Business Practice Location Address City Name:
CLINTON TWP
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48038-6309
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-286-8800
Provider Business Practice Location Address Fax Number:
586-286-8068
Provider Enumeration Date:
04/25/2008

Additional Information

Authorized Official

Authorized Official Last Name:
KOWYNIA
Authorized Official First Name:
PETER
Authorized Official Middle Name:
DAVID
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
586-212-0606

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  4301051240 , 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: 02 0502600 . This is a "BLUE CROSS BLUE SHIELD OF MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 102873117 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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