Provider Demographics
NPI:1033730098
Name:MICHIGAN ADVANCED SURGICAL CENTER, PLLC
Entity Type:Organization
Organization Name:MICHIGAN ADVANCED SURGICAL CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:A
Authorized Official - Last Name:POULSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-434-3211
Mailing Address - Street 1:27101 SCHOENHERR RD STE 300
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48088-4700
Mailing Address - Country:US
Mailing Address - Phone:586-434-3210
Mailing Address - Fax:586-434-3214
Practice Address - Street 1:27101 SCHOENHERR RD STE 300
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48088-4700
Practice Address - Country:US
Practice Address - Phone:586-434-3210
Practice Address - Fax:586-434-3214
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-30
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MICV0011846Medicaid