Healthcare Provider Details

I. General information

NPI: 1417246133
Provider Name (Legal Business Name): ORMC ANESTHESIOLOGIST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2011
Last Update Date: 04/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22401 FOSTER WINTER DR
SOUTHFIELD MI
48075-3724
US

IV. Provider business mailing address

P O BOX 1123 255 WEST MICHIGAN AVENUE
JACKSON MI
49204-1123
US

V. Phone/Fax

Practice location:
  • Phone: 248-423-5151
  • Fax: 517-787-4146
Mailing address:
  • Phone: 800-516-5315
  • Fax: 517-787-7365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State

VIII. Authorized Official

Name: SAMIR F. FULEIHAN
Title or Position: AUTHORIZED REPRESENTATIVE
Credential: MD
Phone: 313-993-0822