Provider Demographics
NPI:1306283957
Name:MICHIGAN ENDOSCOPY CENTER AT PROVIDENCE PARK
Entity type:Organization
Organization Name:MICHIGAN ENDOSCOPY CENTER AT PROVIDENCE PARK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CRISTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:TRAHEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-465-9220
Mailing Address - Street 1:47601 GRAND RIVER AVE STE D-110
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48374-1233
Mailing Address - Country:US
Mailing Address - Phone:248-465-9220
Mailing Address - Fax:248-347-1915
Practice Address - Street 1:47601 GRAND RIVER AVE STE D-110
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48374-1233
Practice Address - Country:US
Practice Address - Phone:248-465-9220
Practice Address - Fax:248-347-1915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-22
Last Update Date:2025-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical