1629075106 NPI number — MICHIGAN ENDOSCOPY CENTER LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629075106 NPI number — MICHIGAN ENDOSCOPY CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHIGAN ENDOSCOPY CENTER 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:
1629075106
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2500 YORK RD STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JAMISON
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18929-1098
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-589-9024
Provider Business Mailing Address Fax Number:
833-705-6301

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30055 NORTHWESTERN HWY
Provider Second Line Business Practice Location Address:
SUITE L-60
Provider Business Practice Location Address City Name:
FARMINGTON HILLS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48334-3230
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-865-6555
Provider Business Practice Location Address Fax Number:
248-865-6554
Provider Enumeration Date:
06/30/2005

Additional Information

Authorized Official

Authorized Official Last Name:
HOHLFELD
Authorized Official First Name:
SHARON
Authorized Official Middle Name:
M
Authorized Official Title or Position:
CO-TREASURER
Authorized Official Telephone Number:
215-589-9024

Provider Taxonomy Codes

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

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

  • Identifier: 23-C0001045 . This is a "MEDICARE ASC NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 23D1006055 . This is a "CLIA CERTIFICATE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 23389 . This is a "AAAHC ACCREDITATION" identifier . This identifiers is of the category "OTHER".
  • Identifier: 40373 . This is a "BCBSMI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 010473 . This is a "CERTIFICATE OF NEED" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 636910 . This is a "STATE LICENESE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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