Healthcare Provider Details

I. General information

NPI: 1255510525
Provider Name (Legal Business Name): EYE SURGERY CENTER OF MICHIGAN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2007
Last Update Date: 03/22/2021
Certification Date: 03/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3455 LIVERNOIS
TROY MI
48083-5063
US

IV. Provider business mailing address

3455 LIVERNOIS RD
TROY MI
48083-5063
US

V. Phone/Fax

Practice location:
  • Phone: 248-619-2020
  • Fax:
Mailing address:
  • Phone: 248-619-2020
  • Fax: 248-619-7150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QS0132X
TaxonomyOphthalmologic Surgery Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LESLIE DAVID GROSINGER
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 248-333-2900