Provider Demographics
NPI:1225779325
Name:SOUTHGATE ARDENT PLLC
Entity Type:Organization
Organization Name:SOUTHGATE ARDENT PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:BURKEEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-284-8088
Mailing Address - Street 1:13703 NORTHLINE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHGATE
Mailing Address - State:MI
Mailing Address - Zip Code:48195-1866
Mailing Address - Country:US
Mailing Address - Phone:734-284-8088
Mailing Address - Fax:734-284-0522
Practice Address - Street 1:13703 NORTHLINE RD
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-1866
Practice Address - Country:US
Practice Address - Phone:734-284-8088
Practice Address - Fax:734-284-0522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1447822572OtherNPI
MI1053768432OtherNPI