Healthcare Provider Details

I. General information

NPI: 1467788729
Provider Name (Legal Business Name): WATERFORD SURGICAL CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2009
Last Update Date: 10/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5220 HIGHLAND RD SUITE 100
WATERFORD MI
48327-1975
US

IV. Provider business mailing address

5220 HIGHLAND RD SUITE 100
WATERFORD MI
48327-1975
US

V. Phone/Fax

Practice location:
  • Phone: 248-889-4580
  • Fax: 248-889-4582
Mailing address:
  • Phone: 248-889-4580
  • Fax: 248-889-4582

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. BASHAR SUCCAR
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 248-889-4580