MEDICARE: ADVANCED SLEEP DISORDER CENTER LLC

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	2084S0012X	Sleep Medicine (Psychiatry & Neurology) Physician	GA405226	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1114095510
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVANCED SLEEP DISORDER CENTER LLC

Provider Business Mailing Address
First Line	:	PO BOX 250681
Second Line	:
City	:	FRANKLIN
State	:	MI
Zip	:	48025-0681
Country	:	US
Telephone Number	:	248-851-1264
Fax Number	:	248-851-5096

Provider Business Practice Location Address
First Line	:	1159 E MICHIGAN AVE
Second Line	:	SUITE D
City	:	YPSILANTI
State	:	MI
Zip	:	48198-5807
Country	:	US
Telephone Number	:	734-480-4250
Fax Number	:	734-480-4251

Authorized Official
Title or Position	:	MANAGER
Name	:	KENNETH J PHILLIPS
Credential	:
Telephone Number	:	248-851-1264

Provider Enumeration Date	:	12/01/2006
Last Update Date	:	08/22/2020

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