Healthcare Provider Details

I. General information

NPI: 1104867910
Provider Name (Legal Business Name): COMMUNITY ORTHOPEDIC SURGERY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 06/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5315 ELLIOTT DR SUITE 202
YPSILANTI MI
48197-8634
US

IV. Provider business mailing address

5315 ELLIOTT DR SUITE 202
YPSILANTI MI
48197-8634
US

V. Phone/Fax

Practice location:
  • Phone: 734-712-0600
  • Fax: 734-712-0522
Mailing address:
  • Phone: 734-712-0600
  • Fax: 734-712-0522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License NumberRN043612
License Number StateMI

VIII. Authorized Official

Name: MRS. SANDRA D BOLTON
Title or Position: BILLING MANAGER
Credential:
Phone: 734-712-0635