Provider Demographics
NPI:1295865392
Name:SOUTHEAST MICHIGAN SURGICAL HOSPITAL, LLC
Entity Type:Organization
Organization Name:SOUTHEAST MICHIGAN SURGICAL HOSPITAL, LLC
Other - Org Name:SOUTHEAST MICHIGAN SURGICAL HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:A
Authorized Official - Last Name:POULSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-427-1000
Mailing Address - Street 1:21230 DEQUINDRE RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48091-2279
Mailing Address - Country:US
Mailing Address - Phone:586-427-1000
Mailing Address - Fax:586-759-0237
Practice Address - Street 1:21230 DEQUINDRE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48091-2279
Practice Address - Country:US
Practice Address - Phone:586-427-1000
Practice Address - Fax:586-759-0237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
213E00000X
MI500100213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0E00146OtherPODIATRIST GROUP ID #
MI0E01458OtherBCBS PROVIDER ID #
MI2619390Medicaid
ON79780Medicare UPIN
MI0N79800Medicare ID - Type UnspecifiedPODIATRIST