MEDICARE: OAKWOOD SOUTHSHORE SURGERY CENTER, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA1903X	Ambulatory Surgical Clinic/Center	826847	MI

General Provider Information

NPI Number	:	1083653935
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OAKWOOD SOUTHSHORE SURGERY CENTER, LLC

Provider Business Mailing Address
First Line	:	5452 FORT ST
Second Line	:	SUITE 100
City	:	TRENTON
State	:	MI
Zip	:	48183-4601
Country	:	US
Telephone Number	:	734-479-7070
Fax Number	:	734-479-7074

Provider Business Practice Location Address
First Line	:	5452 FORT ST
Second Line	:	SUITE 100
City	:	TRENTON
State	:	MI
Zip	:	48183-4601
Country	:	US
Telephone Number	:	734-479-7070
Fax Number	:	734-479-7074

Authorized Official
Title or Position	:	BOARD MANAGER
Name	:	MR. BARRY M CULLEN
Credential	:
Telephone Number	:	313-982-3010

Provider Enumeration Date	:	06/06/2006
Last Update Date	:	10/20/2009

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