Provider Demographics
NPI:1003079344
Name:MICHIGAN CENTER FOR ORTHOPEDIC SURGERY PLC
Entity Type:Organization
Organization Name:MICHIGAN CENTER FOR ORTHOPEDIC SURGERY PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHIVAJEE
Authorized Official - Middle Name:V
Authorized Official - Last Name:NALLAMOTHU
Authorized Official - Suffix:
Authorized Official - Credentials:D O
Authorized Official - Phone:248-620-2325
Mailing Address - Street 1:5701 BOW POINTE DR
Mailing Address - Street 2:STE 300
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-3198
Mailing Address - Country:US
Mailing Address - Phone:248-620-2325
Mailing Address - Fax:248-620-2326
Practice Address - Street 1:17200 SILVER PKWY
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-3423
Practice Address - Country:US
Practice Address - Phone:810-714-9660
Practice Address - Fax:810-714-9661
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-08
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0P47310Medicare PIN