MEDICARE: MIDLAND SURGICAL GROUP 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	208600000X	Surgery Physician	047857	MI
2	208600000X	Surgery Physician	040961	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	020E66017	OTHER	MI	BCBS

General Provider Information

NPI Number	:	1689662926
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIDLAND SURGICAL GROUP PC

Provider Business Mailing Address
First Line	:	4007 ORCHARD DR
Second Line	:	SUITE 2003
City	:	MIDLAND
State	:	MI
Zip	:	48640-6190
Country	:	US
Telephone Number	:	989-631-1221
Fax Number	:	989-631-6686

Provider Business Practice Location Address
First Line	:	4007 ORCHARD DR
Second Line	:	SUITE 2003
City	:	MIDLAND
State	:	MI
Zip	:	48640-6187
Country	:	US
Telephone Number	:	989-631-1221
Fax Number	:	989-631-6686

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ELLSWORTH EMIL LUDWIG
Credential	:	MD
Telephone Number	:	989-631-1221

Provider Enumeration Date	:	10/11/2005
Last Update Date	:	10/01/2010

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Directions to “MIDLAND SURGICAL GROUP PC ” Practice Location

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