Provider Demographics
NPI:1295816932
Name:MACOMB SURGICAL ASSOCIATES,P.C.
Entity Type:Organization
Organization Name:MACOMB SURGICAL ASSOCIATES,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:586-228-3800
Mailing Address - Street 1:37400 GARFIELD RD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48036-3648
Mailing Address - Country:US
Mailing Address - Phone:586-228-3800
Mailing Address - Fax:586-228-9800
Practice Address - Street 1:37400 GARFIELD RD
Practice Address - Street 2:SUITE 120
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48036-3648
Practice Address - Country:US
Practice Address - Phone:586-228-3800
Practice Address - Fax:586-228-9800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI013279208600000X
MI0070812086S0129X
MI0087712086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4837559Medicaid
MI3464424Medicaid
MI2125953Medicaid
MI4401008Medicaid
MIE26084Medicare UPIN
MI4401008Medicaid
MI2125953Medicaid
MIH61334Medicare UPIN
MI0P28900Medicare ID - Type UnspecifiedGROUP ID NUMBER