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General NPI Number Information
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NPI Number | 1952576431
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Entity Type | Organization
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Legal Business Name | NORTHEAST SURGICAL SPECIALISTS, PC
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Dates
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Enumeration Date | 04/25/2008
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Last Update Date | 03/21/2013
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Provider Practice Location Address
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Address Line | 43211 DALCOMA DR SUITE 4
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City | CLINTON TWP
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State | MI
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Zip | 48038-6309
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Country | US
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Telephone | 586-286-8800
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Fax | 586-286-8068
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Provider Business Mailing Address
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Address Line | 43211 DALCOMA DR SUIT 4
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City | CLINTON TWP
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State | MI
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Zip | 48038-6309
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Country | US
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Telephone | 586-286-8800
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Fax | 586-286-8068
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Authorized Official
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Title or Position | OWNER
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Name | DR. PETER DAVID KOWYNIA
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Credential | M.D.
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Telephone | 586-212-0606
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 4301051240
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License Number State | MI
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