Provider Demographics
NPI:1073818654
Name:ROYAL OAK SURGICAL CENTER, LLC
Entity Type:Organization
Organization Name:ROYAL OAK SURGICAL CENTER, LLC
Other - Org Name:ROYAL OAK SURGICAL CENTER PLLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRITTNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:CUNNINGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:BSN
Authorized Official - Phone:248-658-0878
Mailing Address - Street 1:5130 COOLIDGE HWY STE 120
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-1001
Mailing Address - Country:US
Mailing Address - Phone:248-658-0878
Mailing Address - Fax:248-435-0930
Practice Address - Street 1:5130 COOLIDGE HIWAY
Practice Address - Street 2:SUITE 120
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073
Practice Address - Country:US
Practice Address - Phone:248-658-0878
Practice Address - Fax:248-435-0930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-13
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI636902261QA1903X
MI1010000053261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5122Medicare PIN
23C0001070Medicare Oscar/Certification