Healthcare Provider Details

I. General information

NPI: 1578530630
Provider Name (Legal Business Name): GENESIS SURGERY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2006
Last Update Date: 03/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 E JOLLY RD
LANSING MI
48910-8542
US

IV. Provider business mailing address

3400 E JOLLY RD
LANSING MI
48910-8542
US

V. Phone/Fax

Practice location:
  • Phone: 517-272-1063
  • Fax: 517-272-1685
Mailing address:
  • Phone: 517-272-1063
  • Fax: 517-272-1685

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number336817
License Number StateMI

VIII. Authorized Official

Name: DR. DAVID DESTRISAC
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 517-272-1063