MEDICARE: NEWCO AMBULATORY SURGERY CENTER, LLP

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	746818	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4563971	OTHER		CIGNA
2	30036708	OTHER		FIRST HEALTH
3	32463	OTHER		HEALTH PLAN OF MICHIGAN
4	40221	OTHER	MI	BLUE CROSS BLUE SHIELD
5	40221	OTHER		BLUE CARE NETWORK
6	139016	OTHER		PREFERRED CHOICES
7	139016	OTHER		CARE CHOICES
8	143728	OTHER	MI	GREAT LAKES HEALTH PLAN

General Provider Information

NPI Number	:	1629079611
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEWCO AMBULATORY SURGERY CENTER, LLP

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

Provider Business Practice Location Address
First Line	:	4190 24TH AVE
Second Line	:
City	:	FORT GRATIOT
State	:	MI
Zip	:	48059-3882
Country	:	US
Telephone Number	:	810-989-7649
Fax Number	:	810-989-7652

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. TIMOTHY P CONNELL
Credential	:
Telephone Number	:	810-989-7751

Provider Enumeration Date	:	08/02/2005
Last Update Date	:	08/22/2020

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