Healthcare Provider Details

I. General information

NPI: 1942942511
Provider Name (Legal Business Name): SOUTHEAST MICHIGAN SURGICAL HOSPITAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2022
Last Update Date: 04/12/2022
Certification Date: 04/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21230 DEQUINDRE RD
WARREN MI
48091-2279
US

IV. Provider business mailing address

21230 DEQUINDRE RD
WARREN MI
48091-2279
US

V. Phone/Fax

Practice location:
  • Phone: 810-275-9333
  • Fax:
Mailing address:
  • Phone: 810-275-9333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State

VIII. Authorized Official

Name: MOHAMMAD NADIR IJAZ
Title or Position: COO
Credential:
Phone: 810-275-9371