=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760770903
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ASSOCIATED SURGICAL CENTER OF DEARBORN LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/20/2011
-----------------------------------------------------
Last Update Date | 09/01/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 24420 FORD RD
-----------------------------------------------------
City | DEARBORN HEIGHTS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48127-3233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-673-5917
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24420 FORD RD
-----------------------------------------------------
City | DEARBORN HEIGHTS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48127-3233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-673-5917
-----------------------------------------------------
Fax | 314-667-6915
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MAZIN YALDO
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 313-202-9400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------