1629079611 NPI number — NEWCO AMBULATORY SURGERY CENTER, LLP

Table of content: (NPI 1629079611)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629079611 NPI number — NEWCO AMBULATORY SURGERY CENTER, LLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEWCO AMBULATORY SURGERY CENTER, LLP
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:
6
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:
1629079611
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4190 24TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT GRATIOT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48059-3882
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:
810-989-7652

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4190 24TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT GRATIOT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48059-3882
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-989-7649
Provider Business Practice Location Address Fax Number:
810-989-7652
Provider Enumeration Date:
08/02/2005

Additional Information

Authorized Official

Authorized Official Last Name:
CONNELL
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
P
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
810-989-7751

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  746818 , 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: 4563971 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 30036708 . This is a "FIRST HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 32463 . This is a "HEALTH PLAN OF MICHIGAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 40221 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 40221 . This is a "BLUE CARE NETWORK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 139016 . This is a "PREFERRED CHOICES" identifier . This identifiers is of the category "OTHER".
  • Identifier: 139016 . This is a "CARE CHOICES" identifier . This identifiers is of the category "OTHER".
  • Identifier: 143728 . This is a "GREAT LAKES HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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