Provider Demographics
NPI:1275790206
Name:BEAUMONT WEST BLOOMFIELD ASC LLC
Entity Type:Organization
Organization Name:BEAUMONT WEST BLOOMFIELD ASC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROJECT COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:CONNOLLY
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:248-798-3200
Mailing Address - Street 1:6900 ORCHARD LAKE RD
Mailing Address - Street 2:LL100
Mailing Address - City:W BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-3405
Mailing Address - Country:US
Mailing Address - Phone:248-406-2400
Mailing Address - Fax:248-406-2401
Practice Address - Street 1:6900 ORCHARD LAKE RD
Practice Address - Street 2:LL100
Practice Address - City:W BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-3405
Practice Address - Country:US
Practice Address - Phone:248-406-2400
Practice Address - Fax:248-406-2401
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BEAUMONT WEST BLOOMFIELD ASC LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-19
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty