Healthcare Provider Details

I. General information

NPI: 1942459672
Provider Name (Legal Business Name): PROVIDENCE PARK ANESTHESIA ASSOCIATES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2008
Last Update Date: 09/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47601 GRAND RIVER AVE
NOVI MI
48374-1233
US

IV. Provider business mailing address

19855 OUTER DR STE L4E
DEARBORN MI
48124-2027
US

V. Phone/Fax

Practice location:
  • Phone: 248-465-4100
  • Fax:
Mailing address:
  • Phone: 313-541-6420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DOMINICK LAGO
Title or Position: AUTHORIZED REPRESENTATIVE
Credential: MD
Phone: 800-853-8989