Healthcare Provider Details

I. General information

NPI: 1982802203
Provider Name (Legal Business Name): BEAUMONT WEST BLOOMFIELD ASC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2007
Last Update Date: 12/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6900 ORCHARD LAKE ROAD SUITE LL100
WEST BLOOMFIELD MI
48322
US

IV. Provider business mailing address

6900 ORCHARD LAKE ROAD SUITE LL100
WEST BLOOMFIELD MI
48322
US

V. Phone/Fax

Practice location:
  • Phone: 248-406-2400
  • Fax: 248-406-2401
Mailing address:
  • Phone: 248-406-2400
  • Fax: 248-406-2401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number1010000081
License Number StateMI

VIII. Authorized Official

Name: MR. JOHN T FOX
Title or Position: CEO
Credential:
Phone: 248-213-3334