=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790109445
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MICHIGAN AMBULATORY SURGICAL CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2014
-----------------------------------------------------
Last Update Date | 04/14/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 22000 GREENFIELD RD
-----------------------------------------------------
City | OAK PARK
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48237-2500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-206-2990
-----------------------------------------------------
Fax | 248-206-2991
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22000 GREENFIELD RD
-----------------------------------------------------
City | OAK PARK
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48237-2500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-206-2990
-----------------------------------------------------
Fax | 248-206-2991
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MS. JUSTINE BRECKENRIDGE CORDAY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 248-206-2990
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------