Provider Demographics
NPI:1114095510
Name:ADVANCED SLEEP DISORDER CENTER LLC
Entity Type:Organization
Organization Name:ADVANCED SLEEP DISORDER CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:J
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-851-1264
Mailing Address - Street 1:PO BOX 250681
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:MI
Mailing Address - Zip Code:48025-0681
Mailing Address - Country:US
Mailing Address - Phone:248-851-1264
Mailing Address - Fax:248-851-5096
Practice Address - Street 1:1159 E MICHIGAN AVE
Practice Address - Street 2:SUITE D
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48198-5807
Practice Address - Country:US
Practice Address - Phone:734-480-4250
Practice Address - Fax:734-480-4251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIGA4052262084S0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4618122Medicaid
MI0N87860Medicare ID - Type UnspecifiedGROUP