=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104558287
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUSSAN J SALAS MD PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/28/2022
-----------------------------------------------------
Last Update Date | 08/24/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14555 LEVAN RD STE 312
-----------------------------------------------------
City | LIVONIA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48154-5085
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-855-4358
-----------------------------------------------------
Fax | 734-744-4505
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14555 LEVAN RD STE 312
-----------------------------------------------------
City | LIVONIA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48154-5085
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-855-4358
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SUSSAN SALAS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 734-855-4358
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207T00000X
-----------------------------------------------------
Taxonomy Name | Neurological Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------