MEDICARE: CATARACT SPECIALTY SURGICAL 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	207W00000X	Ophthalmology Physician
2	261QA1903X	Ambulatory Surgical Clinic/Center	636901	MI

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00089786	OTHER		RR MEDICARE

General Provider Information

NPI Number	:	1528061918
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CATARACT SPECIALTY SURGICAL CENTER, LLC

Provider Business Mailing Address
First Line	:	28747 WOODWARD AVE
Second Line	:	LOWER LEVEL
City	:	BERKLEY
State	:	MI
Zip	:	48072-0914
Country	:	US
Telephone Number	:	248-584-4602
Fax Number	:	248-584-4630

Provider Business Practice Location Address
First Line	:	28747 WOODWARD AVE LOWR LEVEL
Second Line	:
City	:	BERKLEY
State	:	MI
Zip	:	48072-0931
Country	:	US
Telephone Number	:	248-584-4602
Fax Number	:	248-584-4630

Authorized Official
Title or Position	:	ADMINISTATOR
Name	:	DEBORAH JANKOWSKI
Credential	:	BSN, RN
Telephone Number	:	248-586-4602

Provider Enumeration Date	:	05/31/2005
Last Update Date	:	05/16/2022

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