Healthcare Provider Details

I. General information

NPI: 1558072629
Provider Name (Legal Business Name): MICHIGAN SPECIALTY SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2022
Last Update Date: 11/01/2023
Certification Date: 11/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6886 SASHABAW ROAD
CLARKSTON MI
48348-4732
US

IV. Provider business mailing address

6886 SASHABAW ROAD
CLARKSTON MI
48348-4732
US

V. Phone/Fax

Practice location:
  • Phone: 248-707-3112
  • Fax: 248-707-3113
Mailing address:
  • Phone: 248-707-3112
  • Fax: 248-707-3113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. AMIR-KIANOOSH FALLAHI
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 810-953-0500