MEDICARE: DOWNRIVER SURGERY CENTER, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	2901012910	MI

General Provider Information

NPI Number	:	1023295474
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DOWNRIVER SURGERY CENTER, PC

Provider Business Mailing Address
First Line	:	1823 FORT ST
Second Line	:
City	:	WYANDOTTE
State	:	MI
Zip	:	48192-3545
Country	:	US
Telephone Number	:	734-285-2550
Fax Number	:	734-285-5375

Provider Business Practice Location Address
First Line	:	1823 FORT ST
Second Line	:
City	:	WYANDOTTE
State	:	MI
Zip	:	48192-3545
Country	:	US
Telephone Number	:	734-285-2550
Fax Number	:	734-285-5375

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. RONALD MORRIS
Credential	:	DDS
Telephone Number	:	734-285-2550

Provider Enumeration Date	:	01/29/2008
Last Update Date	:	06/11/2008

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