Provider Demographics
NPI:1144382789
Name:SURGICAL SPECIALISTS OF ST. JOSEPH, P.C.
Entity Type:Organization
Organization Name:SURGICAL SPECIALISTS OF ST. JOSEPH, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELYN
Authorized Official - Middle Name:A
Authorized Official - Last Name:HASTINGS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-983-3368
Mailing Address - Street 1:2990 NILES RD
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-8607
Mailing Address - Country:US
Mailing Address - Phone:269-983-3368
Mailing Address - Fax:269-983-2758
Practice Address - Street 1:2990 NILES RD
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-8607
Practice Address - Country:US
Practice Address - Phone:269-983-3368
Practice Address - Fax:269-983-2758
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI020A110340OtherBCBS GROUP
MI020A110340OtherBCBS GROUP