MEDICARE: SURGICAL SPECIALIST OF W MICHIGAN

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	208600000X	Surgery Physician

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CM4297	OTHER	MI	RR MEDICARE

General Provider Information

NPI Number	:	1457383937
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SURGICAL SPECIALIST OF W MICHIGAN

Provider Business Mailing Address
First Line	:	6401 PRAIRIE ST
Second Line	:	SUITE 1700
City	:	MUSKEGON
State	:	MI
Zip	:	49444-7840
Country	:	US
Telephone Number	:	800-353-5420
Fax Number	:	866-597-5366

Provider Business Practice Location Address
First Line	:	6401 PRAIRIE ST
Second Line	:	SUITE 1700
City	:	MUSKEGON
State	:	MI
Zip	:	49444-7840
Country	:	US
Telephone Number	:	800-353-5420
Fax Number	:	866-597-5366

Authorized Official
Title or Position	:	DOCTOR
Name	:	MR. RICHARD J WOREL
Credential	:	DO, FACOS
Telephone Number	:	800-353-5420

Provider Enumeration Date	:	07/07/2006
Last Update Date	:	02/13/2008

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