Provider Demographics
NPI:1083653935
Name:OAKWOOD SOUTHSHORE SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:OAKWOOD SOUTHSHORE SURGERY CENTER, LLC
Other - Org Name:OAKWOOD SOUTHSHORE SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BOARD MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:M
Authorized Official - Last Name:CULLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-982-3010
Mailing Address - Street 1:5452 FORT ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TRENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48183-4601
Mailing Address - Country:US
Mailing Address - Phone:734-479-7070
Mailing Address - Fax:734-479-7074
Practice Address - Street 1:5452 FORT ST
Practice Address - Street 2:SUITE 100
Practice Address - City:TRENTON
Practice Address - State:MI
Practice Address - Zip Code:48183-4601
Practice Address - Country:US
Practice Address - Phone:734-479-7070
Practice Address - Fax:734-479-7074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-06
Last Update Date:2009-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI826847261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P11500Medicare UPIN
MI23C0001055Medicare ID - Type UnspecifiedPROVIDER NUMBER